



























































NOTES ON 
MEDICAL DIAGNOSIS 


FOR 

STUDENTS AND PRACTITIONERS 

OF 

DENTISTRY 


BY 

CHARLES CLIFTON BROWNING 

M.D., F.A.C.P" 

Professor of Medical Diagnosis, Dental Department of Univer¬ 
sity of Southern California; 

Professor of Diseases of the Chest, College of Medical 
Evangelists, Los Angeles, California; 

Lecturer on Tuberculosis and Diseases of the Chest, 

Los Angeles Medical Department, University 
of California; 

Chief of Visiting Staff, Tuberculosis Department, 

Los Angeles General Hospital; 

Member Amercan Medical Association and 
Component Societies. 

Los Angeles, California 


T?C7/ 
32 5 


Dedicated hy the Author to his Wife 
HELEN E. BROWNING 


COPYRIGHT 1924 

By 

CHAS. C. BROWNING, M.D., F.A.C.P. 

Los Angeles, Calif. 



'•> 


JUN i I 1924 


PRESS OF 

PHILLIPS PRINTING CO. 


©C1A792805 

/til A t 


PREFACE 


NOTES ON MEDICAL DIAGNOSIS FOR 
STUDENTS AND PRACTITIONERS 
OF DENTISTRY 

In 1919 I was invited to give a course of 
sixteen lectures to the Junior Class of Dentis¬ 
try of the University of Southern California 
on the subject of Medical Diagnosis. 

The object of the course was to give instruc¬ 
tion regarding conditions which would enable 
them to avoid complications which might arise 
during their professional duties, recognize dis¬ 
ease, the existence or importance of which 
the patient had not known, and co-operate in¬ 
telligently with the health authorities and allied 
officers in the control of communicable dis¬ 
eases, and the promotion of public health 
work. 

The selection and treatment of subjects was 
left to my judgment. 

The consideration of each subject has been 
from the practical standpoint of usefulness to 
the dentist. Only the salient points, from this 
standpoint, have been emphasized in the lec¬ 
tures and more briefly rn the notes. 

I was unable to find a textbook which ap¬ 
peared to me to have been well adapted for 
this course. All of the works were so com¬ 
prehensive that, with the limited time alloted 
to the subject, details were likely to result in 
confusion. For this reason brief lecture notes 


i 


were mimeographed and distributed to the 
members of previous classes. 

During the preparation of these notes, I con¬ 
sulted many authorities and drew liberally 
from their writings, using at times extensive 
quotations when the manner of presentation of 
the subject was applicable. Memorandums 
were not made as to the sources of informa¬ 
tion. These quotations were used or altered 
in such manner as to adapt them to my use. 
There was no thought at that time that the 
notes would appear excepting in mimeo¬ 
graphed form; so no effort was made to segre¬ 
gate abstracts and to give credit to the indi¬ 
vidual authors. It would, at this time, be ex¬ 
ceedingly difficult to do so. The following are 
some of the books which have been most help¬ 
ful to me, viz.: Medical Diagnosis, Green; 
Diseases of the Chest and the Principles of 
Physical Diagnosis, Norris and Landis; Gen¬ 
eral and Dental Pathology, Endelman and 
Wagoner; Practice of Medicine, Dayton; 
Modern Medicine, Barker; Forchheimer’s 
Therapeusis of Internal Diseases, and others. 

Additions have been made from time to 
time to the notes. The classes have increased 
from thirty-four in 1919 to one hundred and 
sixty-four in 1923-4. 

When the question of mimeographing the 
notes for this year was considered, it was sug¬ 
gested that they be printed and issued in book 
form. 

I express my gratitude for the valuable as- 


4 


sistance of Dr. Julio Endelman. It is through 
my association with him that my interest has 
been increased and maintained, and the impor¬ 
tance of a closer relationship between the den¬ 
tal and medical professions more fully appre¬ 
ciated. Through this association I have had 
access to his pathological laboratories and 
profited by his pathological studies. These 
have been the foundation for clinical work 
in co-operation with members of the dental 
profession, which has proven of greatest im¬ 
portance through the care of focal infections, 
particularly those of the peridental tissues. I 
am under obligation to him for many helpful 
suggestions in the preparation of the manu¬ 
script and publication of these notes. 

I express my appreciation to Dr. Lewis E. 
Ford, Dean, and Dr. A. C. La Touche, Secre¬ 
tary, of the College of Dentistry of the Uni¬ 
versity of Southern California, for their co¬ 
operation and courtesies extended since my 
affiliation with the College, and to other mem¬ 
bers of the faculty; also to Dr. Gladys Patric 
Shachovitch, who rendered valuable assistance 
in the preparation of the manuscript. 


5 



DIAGNOSIS 


SCOPE 

HISTORY RECORD 
HISTORY TAKING 



MEDICAL DIAGNOSIS 
FOR DENTISTS 

Scope Diagnosis, naming disease, means more 

than naming a disease, and necessitates a 
knowledge of etiological factors, a correct 
estimate of the constitutional peculiarities of 
the patient, the nature and extent of path¬ 
ological changes, the effect of age, occupa¬ 
tion, residence, habits, heredity, past ail¬ 
ments, and even the personal characteristics 
of the individual. 

History- Diagnosis demands a sufficiency of facts, 

Record truthfully recorded, intelligently co-ordinated 
and viewed without pre-conceived prejudice. 
Every professional man should carefully keep 
a record of every case and form a habit of re¬ 
porting those of special interest, the knowl¬ 
edge of which will be helpful to other mem¬ 
bers of his profession. 

History Knowledge of clinical symptoms in a 

Taking given case depends either upon (a) history 
(what is told), or (b) what is seen or deter¬ 
mined by the examiner, i.e., (a) subjective 
symptoms, or (b) objective symptoms. Sub¬ 
jective symptoms depend upn information 
obtained from the patient, and other per¬ 
sons. These symptoms should be carefully 
considered in the light of knowledge ob¬ 
tained. If statements are made which seem 
to : be unreasonable, sufficient discussion 
should occur, that clear understanding may 
be secured, if possible. It is generally un- 


wise to enter into an argument or express 
disagreement with the history given. Certain 
single symptoms may name the disease; such 
are termed pathognomic. Objective symptoms 
include bacteriological and chemical labora¬ 
tory tests, and physical signs (physical diag¬ 
nosis). 

Physical Diagnosis consists in employing 
the senses,—sight, smell, touch and hearing, 
—to determine the condition of tissues. 
These may be altered by pathological states 
as regards density, elasticity or content of 
fluid or gas. Organs may change size or 
location. Such changes may be detected by 
physical signs. 


10 


PHYSICAL SIGNS 


The outward Signs of Disease 

Inspection 

First Impressions 

General Appearance 

Color of Skin 

Anaemic Types 

Skin in Certain Diseases of the Heart 

Cyanosis, Underlying Cause 

High Color 

Drug Poisoning 

General Hyperemia 

Jaundice 

Obstructive Jaundice 

Facial Changes 

Nephritis 

Baggy Eyelids 

Uremia 

Syphilis 

Moisture of the Skin 
Voice. 


11 




PHYSICAL SIGNS 


The Outward Signs of Disease 


INSPECTION 


First The first glance, general appearance, move- 

Impressionsment. manner of speech or an odor may sug¬ 
gest diagnosis and prognosis. 

General Appearance. 


Color 
of Skin 


Anemic 

Types 


The colors of the skin most frequently noted 
are ruddiness, pallor and cyanosis. Anemia 
is a deficiency in the red cells of the blood, 
and in the percentage of hemoglobin, or in 
both. The pale face may or may not mean 
true anemia, and a high color may co-exist 
with a low hemoglobin percentage, because 
of capillary congestion. The color of the 
mucous membranes is more reliable, and 
even “rosy chlorotics” usually show pale 
mucous membranes. Conjunctivae free from 
congestion, are favorable for observation. 
The roof of the mouth is frequently a re¬ 
liable location for observation. 

The color varies markedly in different types 
of anemia, being greenish-yellow or almost 
waxy white in pernicious anemia, and a cur¬ 
ious earthy tint in the profound secondary 
anemias of malignant disease, especially of the 
stomach. A positive diagnosis of the type of 
anemia can only be made after careful con¬ 
sideration of casual factors and exhaustive 
laboratory examination. 


13 


Skin in 
Certain 
Diseases 
of the 
Heart 


The pallor of the anemias, aside from those 
due to rapid blood loss, is gradual and per¬ 
sistent. Anemic patients recover slozuly from 
operations, and resist infections poorly . 

The color in certain forms of heart disease 
is both interesting and important Aortic re¬ 
gurgitation is usually associated with a pallor 
of the indoor-worker type, (bluish white) 
without true anemia. In compensated regur¬ 
gitant and obstructive disease of the mitral 
valve the color is often deceptively high. The 
skilled eye sees the duskiness of the underly¬ 
ing cyanosis which shows yet more plainly in 
the mucous membrane of the lips, the skin of 
the ears, nose, patella, and the nails, whose 
pink is replaced by a darker hue or in extreme 
cases by a purplish or black-gray. These pa¬ 
tients zvithstand shock poorly; are poor anes¬ 
thetic risks. 


r •* Cyanosis is a bluish discoloration of the 
Underlying skin, due to imperfect oxidation of the blood. 
Cause Cyanosis, whether general or local, with or 
without true dyspnea, ordinarily indicates ob¬ 
structed venous return, deficient oxidation, or 
commonly both factors, such as may result 
from many causes. Some of these which are 
of more frequent interest to dentists are or¬ 
dinary suffocation, emphysema, pulmonary fib¬ 
rosis ; obstructed glottis, trachea or bronchi, as 
from foreign bodies; mediastinal tumors, or 
other heart and lung lesions. It occurs also in 
acute disease, such as pneumonia, pleurisy with 
pneumothorax (air in the pleural cavity) and, 


14 


to a slight degree, in severe acute bronchitis. 
Paralysis and spasm, particularly of the dia¬ 
phragm, may produce marked cyanosis, as 
may the inhibition of efficient respiration by 
severe pain. No outward signs of disease ex¬ 
ceed cyanosis in importance, and in its ex¬ 
treme persistent form it is met with most fre¬ 
quently in walking patients in two conditions, 
i. e., severe emphysema in the adult, congen¬ 
ital heart disease in the child. It is often as¬ 
sociated with mere chilling of the body sur¬ 
face, hysteria, neuritis, etc. The cause of cy¬ 
anosis should he determined before undertak¬ 
ing an operative procedure. 

High A florid face is common in gout, early inter- 

Color stitial nephritis and hepatic cirrhosis, but may 
be due to idiosyncrasy, acne rosacea or ex¬ 
posure. It often suggests an over-luxurious 
and self-indulgent life or the abuse of alco¬ 
holics. Unilateral flushing is often observed 
as a neurosis, in lobar pneumonia on the af¬ 
fected side, and in cases of active pulmonary 
tuberculosis; it may be due to mere pillow 
pressure, migraine, and less commonly to 
irritation of the fibers of the cervical sym¬ 
pathetic, as in aneurysm of the aortic arch. 

Poisoning Local vaso-motor relaxation or paralysis is 

Drug readily distinguished by the lack of turgidity 

of the venous trunks, and it should be remem¬ 
bered that certain forms of drug poisoning, es¬ 
pecially acetanilid and its congeners, nitro- 
benzol, etc., may account for an otherwise in¬ 
explicable and extreme cyanosis. Allow pa- 


15 


tient to recover from effects of the drug 
before administering an anesthetic or perform¬ 
ing an operation not imperative. 

General General hyperaemia is seen in poisoning by 
Hyperaemia belladonna, hyoscyamus, or coal-tar products; 

is common in the trivial fevers of infancy 
and early childhood, and may precede the spe¬ 
cific exanthem in fevers of the eruptive type. 

Jaundice Jaundice is characterized by a yellowish dis- 
(Icterus) coloration of the skin. It is frequently asso¬ 
ciated with digestive disturbance, malaise, 
slow pulse and subnormal temperature. 

Jaundice is either obstructive, as in direct 
or indirect inflammation or obstruction of the 
common bile duct, or toxemic, the latter form 
being wrongly termed hematogenous as ap¬ 
posed to hepatogenous. 

Obstructive Stristly speaking, all cases of jaundice are 
Jaundice obstructive, as even in the toxic form there is 
a high viscidity which favors absorption. 

Symptoms The skin, ocular conjunctiva and oral mu- 
of cous membranes of the throat, lips or tongue 

Obstructive yield the best evidence, especially if the latter 
aun ice are bl anc h e d by the pressure of the finger or 
better by a glass tumbler or micrscope-slide. 
But even a marked discoloration may be invis¬ 
ible by artificial light. By daylight the color 
of the skin varies from a faint or brilliant yel¬ 
low to a deep green or bronze (nelasicterus), 
sometimes simulating Addison’s disease. Such 
cases are seen frequently in the last stages of 
cirrhosis of the liver. The sweat and urine 


16 


are discolored, the pulse and respiration are 
usually slow, the stools are pale gray, pasty 
and fetid, either constipation or diarrhea may 
be present and there may be a troublesome 
pruritus, and even urticarial or pupuric condi¬ 
tions. A marked hemorrhagic tendency is 
shown in severe cases which is of special inter¬ 
est to the surgeon. 

Certain Diseases may cause a change in 

COLOR AND 

PRODUCE CERTAIN CHARACTERISTIC FACIAL 
CHANGES. 

Nephritis In acute nephritis the skin is white, and an 
associated edema produces the peculiar and 
characteristic pasty pallor. In parenchyma¬ 
tous nephritis we meet with pallor, or in its 
late stages a sallow or brownish hue. 

Baggy A tendency to edema exists frequently in 

Eyelids the eyelids, especially in the lower lids is this 
often evident. The pale, puffy and almost 
translucent lid of early morning may later in 
the day become shrunken and wrinkled. The 
condition cannot be cosidered as pathogno¬ 
monic, but should be regarded as suggestive. 
In chronic parenchymatous and in “mixed” 
nephritis, the face may also appear more or 
less puffy, sallow or even fawn-colored. Urin¬ 
alysis should be made. 

The kidneys act as the guardians and elim- 
inants of the blood, and a diminution of their 
function will result in an abnormal condition 
of the blood. 


17 


Uremia A toxic condition occurring with acute or 

chronic nephritis, characterized by convulsive 
seizures, vomiting, blindness, paralysis, dis¬ 
turbance of the heart and respiratory func¬ 
tions, with or without fever, is due to kidney 
or renal insufficiency. 

Renal . This condition is the result of inflamma- 

In*ufficiency tor y p roceS ses in the kidney, as nephritis— 
acute, sub-acute or chronic. 

Nephritis It may be induced by acute and chronic in¬ 
fections, exogenous, as the exanthemata and 
focal infections; and endogenous, as those 
originating in the intestinal tract; also by 
suppression of the eliminative processes of 
the skin, as by intense cold, burns, eczema, 
etc. 

Pregnancy predisposes to kidney insuffic¬ 
iency. Artificially preserved foods and such 
remedies as mercuric bichloride, arsenic, lead, 
phosphorus, alcohol, turpentine and many veg¬ 
etable drugs may excite nephritis or convert 
a chronic condition into an active acute 
nephritis. 

Nephritics take general anesthetics poorly, 
are poor surgical risks and recover slowly. 

Syphilis The permanent upper central and lateral 
incisors or cuspids of the older children are 
often peg-shaped, and notched at their cutting 
. edges, irregular and separated; perforated 
palate (not cleft palate), and saddle nose, 
due to necrosis of the nasal bones; fine linear 
scars radiating from the angles of the mouth 
due to wounding of tissue on the sharp edges 


18 


Moisture 
of the 
Skin 


Voice 


of the irregularly placed teeth, keratitis (in¬ 
flammation of the ocular cornea), and chronic 
otitis media, are suggestive of syphilis. The 
two latter conditions may also be met with in 
persons suffering from tuberculosis. Syphilis 
is unfavorable for healing, the bones are fri¬ 
able; it may be infectious. Aortitis which fre¬ 
quently exists is unfavorable for anesthesia. 
Intrathoracic or abdominal aneurysms may 
develop which frequently terminate in sudden 
death. 

Profuse sweating occurs not only during 
the course of continued fevers when the tem¬ 
perature is normal or subnormal. It may be 
seen in cases of great debility, as in convales¬ 
cence, in severe pain, in malnutrition, in septic 
conditions and in “night sweats” of tubercu¬ 
losis. 

Dryness of the skin may be seen not only 
during the existence of fever, but in cases of 
excessive fluid from the kidneys or bowels, 
or in a swollen condition of the skin or 
subcutaneous tissues, as dropsy. 

Hoarseness and aphonia are at times symp¬ 
toms of great importance, pointing to acute or 
chronic laryngeal disease; the whispering 
voice may be due to edema of the glottis, lar¬ 
yngitis, acute or chronic tuberculosis or mal¬ 
ignant condition, hysteric aphonia, or to a par¬ 
alysis of the vocal cords. 

Acute disease may favor acute ulceration 
folloiving operative procedure, or acute infec¬ 
tions may be disseminated by chronic condi- 


19 


tions; healing may he slow. Operative pro¬ 
cedure may cause greater activity in the 
chronic condition, hence operative procedure 
should he reduced to the minimum. 


CLINICAL HISTORIES 

Previous Illness 
Present Illness 

SYMPTOMS 

Fever 

THE HEART AND BLOOD VESSELS 
Arterial Pulse 
Blood Pressure 


21 









Previous 

Illnesses 


Present 

Ailment 


CLINICAL HISTORIES 

A history of the previous existence of cer¬ 
tain diseases may throw light upon the present 
conditions. 

The patient should tell of his volition, but 
in as few words as possible, the symptoms of 
his disease and their duration. One should 
discriminate between symptoms which are 
general in their nature, common to a large 
number of diseases and subject to various in¬ 
terpretations, and those which are local, pecul¬ 
iar or specific. 

Do not express a disagreement with the 
statements of a patient while obtaining a his¬ 
tory. An argument will frequently prevent 
the securing of important items in the history. 


2 i 


Fever 


Care of 
Ther¬ 
mometer 


SYMPTOMS 

Fever as a clinical manifestation is an ele¬ 
vation of the body temperature. It was for¬ 
merly determined or estimated by the hand, 
but now more accurately by the clinical ther¬ 
mometer. In most acute diseases, as pneu¬ 
monia and typhoid fever, the skin is dry and 
hot. In some of the intense intoxications, as 
small pox, it may be moist. Septic conditions 
are frequently accompanied by fever with 
sweating. 

On the other hand, a high rectal temperature 
may exist in cholera and the surface temper¬ 
ature be as low as 70 degrees. The thermom¬ 
eter is ordinarily applied to one of four points, 
these being in the order of frequency the 
mouth, the axilla, the rectum and the vagina. 

In the use of the thermometer certain pre¬ 
cautions must be observed: 

(a) It should be cleaned before and after 
use. 

(b) The scale should invariably be in¬ 
spected, as the thermometers are self-register¬ 
ing and require to be shaken down after use. 

(c) If used in the mouth, it should be 
placed well under the tongue and held by the 
tightly closed lips, not the teeth, of the patient. 
The time should be from three to five minutes. 

(d) Axillary temperature should be avoid¬ 
ed whenever possible, as being subject to 
greater error variation than in other regions. 


24 


Normal 

Tempera¬ 

ture 


Diagnostic 
Import of 
Fever 


Incipient 

Tubercu¬ 

losis 


If so taken, the thermometer should be placed 
deeply in the axilla, which should have been 
freed from any moisture present, and the el¬ 
bow of that side should be close to the body 
and carried well forward. Axillary readings 
are particulaly misleading in incipient tuber¬ 
culosis or in slightly febrile conditions. 

Physiologists state that in normal persons the 
range may be 99.5° F. as a maximum, and 
97.7° F. as a minimum. This is probably not 
too wide a range, if we consider the extremes 
of temperature in which individuals work. 
The use of some drugs as bromides, coal-tar 
products and others may cause subnormal 
temperature. 

Putting aside the rare cases of hysterical 
temperature and excluding deception and 
faulty technic, one may say fever is primarily 
of value in proving the existence of some or¬ 
ganic ailment. 

Years of observation in private and public- 
practice have convinced the writer that under 
ordinay living conditions, a persistent maxi¬ 
mum daily temperature exceeding 99.2° F. or 
low morning temperature of 97.8° F. not 
otherwise accounted for is probably due to 
tuberculosis. Subnormal temperature which 
persists, not followed by temperature above 
normal, is most frequently due to a chronic 
infection very slightly progressive. By far the 
greater number prove to be cases of incipient 


25 


tuberculosis or chronic appendicitis—condi¬ 
tions recognized but rarely until the last two 
decades. 


2 e 


THE HEART AND BLOOD¬ 
VESSELS 

Arterial Certain conditions of the heart are most 

Pulse readily observed through observation of the 
arterial pulse. It is also a valuable index in 
determining the condition of other portions 
of the body. 

Whenever possible the pulse should be 
taken casually while talking of other matters 
to divert the attention of the patient from the 
pulse taking, and allowance should be made 
for the nervousness incident to examination 
and the effect of physical exertion, as they 
tend to increase the heart action and change 
the condition of the pulse. 

Technic A correct technic is of the utmost impor¬ 
tance and the patient’s arms should be similar¬ 
ly in a position free from restraint, flexion, or 
muscular compression of the vessels. The 
pulse should be taken simultaneously in the 
two radial arteries, and three fingers applied 
lightly over the artery at the wrist. 

Point* to be (1) The size of the artery. (2) Pulse 

Determined rate or frequency. ('3) Regularity of rhythm. 

(4) Uniformity of strength. (5) Syn¬ 
chronism and equality of the right and left 
radial pulses. (6) The force required to ob¬ 
literate them,—tension. (7) Abnormal thick¬ 
ening of the artery,—arterio-sclerosis. 

When the physician’s fingers are applied to 


27 


Pulse 

Frequency 


the artery, the first four points are determined 
almost unconsciously and instantaneously, the 
vessel being lightly rolled under the finger to 
get its size, and pressure made with the upper 
finger until the pulse is lost to the lower, the 
force exerted being the measure of tension. 
The empty artery is then rolled under the 
lower finger to detect any thickening of its 
walls,—arterio-sclerosis; any vessel that can 
thus be felt as a distinct tube is sclerotic and 
hence abnormal. Such may be merely palpa¬ 
ble, distinctly rigid, or carry tiny plaques of 
lime salts. Chronic nephritis may co-exist. 
There is in arterio-sclerosis danger of hemor¬ 
rhage from ruptured cerebral arteries under 
stimulus of a general anesthetic or exictement. 

The average normal rates are; for the first 
year of life from 130-140; from the first to 
the fourth year gradually dropping to 105 or 
110; and so diminishing until the fifteenth or 
sixteenth year when it reaches from 75 to 80 
beats per minute, with extremes of 58 to 90 in 
different individuals. During middle life and 
up to 60 years frequency is slightly diminished, 
sometimes increasing somewhat beyond that 
age. Women show a rate from 5-8 beats a 
minute faster than men, and it is slightly 
slower in tall than in short persons. Any ab¬ 
normal increase in frequency suggests the use 
of the clinical thermometer, and we find that, 
as a rule, the rate increases from 8 to 10 beats 
per minute for each degree of temperature 
above the normal, and further, that the be- 


28 


Technic 


havior of pulse is of both diagnostic and prog- 
nostic importance. 

DETERMINATION OF BLOOD 
PRESSURE 

Fortunately for the clinician, blood pres¬ 
sure may now be measured quickly and accu¬ 
rately by simple and relatively inexpensive 
instruments, nearly all of which depend upon 
the same general principles, i. e., the transla¬ 
tion of the pressure required to obliterate the 
arterial pulse into the height of a mercury 
column in a manometer tube or its equivalent. 

The hollow armlet applied midway between 
shoulder and elbow is inflated by the hand 
bulb until the radial pulse is lost, then by the 
outlet thumb screw the pressure is lowered 
until the pulse return is just perceptible. As 
the pressure is equal in all parts of the closed 
system, the height of the mercury column in 
the manometer tube is an exact index and the 
reading represents the “maximum” or “sys¬ 
tolic” pressure. “Diastolic” or “minimum” 
pressure is determined by noting for ten or 
twelve pulsations the increasing amplitude of 
the pulse wave registered by the mercury col¬ 
umn as the pressure is reduced in 5 mm. series. 
The point causing base line of the maximum 
excursion is the index of diastolic pressure. 
Below that is a limited pressure area of equal, 
amplitudes. The “mean” pressure represents 
the average of systolic and diastolic readings, 
and the “pulse” pressure is the difference be- 


29 


tween the systolic and diastolic readings. Di¬ 
astolic readings run about 25-40 mm. below 
systolic, in low tension they vary from 50-80 
mm., and in aortic regurgitation up to 100 mm. 
A loose band or a rapid or excessively small 
pulse makes diastolic pressure determination 
impossible. In every case the arm band should 
be closely adjusted, the arm supported at the 
heart level, and the same position taken for a 
series of tests. The limit of error in calcar¬ 
eous arteries is but 5-10 mm., and is negligible 
or easily estimated. The same figures repre¬ 
sent the difference between females and males 
and the standing and sitting posture. In nor¬ 
mal pressure four factors are concerned, viz.: 
the initial heart energy, peripheral resistance, 
blood volume and the elasticity of the vessels. 
The normal readings according to Janeway 
are: for young adults, 100-130 mm.; older 
adults, 100-145 mm.; children, 90-110 mm.; 
infants under two years, 75-90 mm. Excite¬ 
ment may cause a rise of 40 mm., and concen¬ 
trated physical effort a slight increase. A 
stethoscope placed over the brachial artery at 
the bend of the elbow is preferred by many as 
having greater accuracy. 

The cuff is inflated to the extent that the 
systolic pressure is obliterated in the radial 
artery. The stethoscope is placed over the 
brachial artery, not touching the cuff, and the 
pressure gradually released. Four phases are 
recognized. 

1. The first clear thumping, pounding 


30 


noise indicates pressure sufficient to force 
blood into artery below the cuff and is the 
systolic pressure. 

2. This is followed by a hiss or murmur, 
which disappears. 

3. This is replaced by a clear sound. 

4. This is followed by a muffled, distant 
sound, which is the beginning of the fourth 
phase or diastolic pressure. 

Both methods may be used at the same time. 

In chronic interstitial nephritis, arterio- 
HigjT* 111 7 sclerosis, high peripheral resistance and in¬ 
creased heart energy bring about high blood 
pressure readings. 

Low The conditions giving the lowest readings 

are shock, collapse and concealed hemorrhage. 
In visible hemorrhage attended by nervous ex¬ 
citement, fear and apprehension, the pressure 
is raised due to the nervous tension. The 
acute infectious diseases, anemias and cachex¬ 
ias, and the terminal stage of all diseases show 
low pressure as does also weakened heart 
muscle. 


31 







INFECTIONS 


IMMUNITY 

INFECTIOUS DISEASES OF THE 
RESPIRATORY TRACT. 

Post-Nasal Adenoids 
Tonsillitis 
Laryngitis, Acute 
Laryngitis, Tuberculous 

ADMINISTRATION OF VACCINES 

FOCAL INFECTIONS 

Influence upon the Heart 

OTHER OF THE INFECTIOUS 
CONDITIONS 

Scarlet Fever 
Measles 

German Measles 
Small-Pox 
Chicken Pox 
Whooping Cough 
Mumps 

Infantile Paralysis 
Typhoid Fever 
Typhus Fever 
Plague 
Rabies 


33 


INFECTIONS 


Infect 

Infection 

Infectious 


“To communicate or transmit the specific 
virus or germs of disease’’ (Gould.) 

To infect by any means, direct or indirect. 

Having the power of infection. 

Infectious diseases are those which are pro¬ 
duced by the introduction and multiplication 
of infectious organisms in the tissue of the 
body. Infectious organisms may belong either 
to the vegetable or animal kingdom; in some 
instances it is difficult to determine to which 
of these kingdoms the organisms belong. 

INFECTIOUS DISEASES ARE COM¬ 
MUNICABLE . THEREFORE ARE PRE¬ 
VENTABLE. INFECTIOUS DISEASES 
ARE RESISTED BY AND RECOVERED 
FROM BY THE ESTABLISHMENT OF 
IMMUNITY. 


35 


IMMUNITY 


Natural 

Acquired 

Passive 

Active 

Partial 

Complete 

Temporary 

Permanent 


When a species or race or individual is not 
susceptible to attack by given organisms, or at 
least not to an extent that diseased conditions 
result. 

When, because of infection or otherwise, 
changes have been produced in the system 
which enable the individual to resist, to a 
greater or less degree, attacks of given organ¬ 
isms which otherwise commonly produce dis¬ 
ease in the species or race. 

ACQUIRED IMMUNITY 

Conferred by introducing immunizing agents 
into the body,—serums or anti-toxins. 

Conferred by producing immunizing agents 
in the body; (development or course of dis¬ 
ease, or introduction of toxins.) 

When it modifies the severity of disease— 
the disease running its ordinary course. 

When it prevents the development of dis¬ 
ease. 

When it produces a cure. 

When the disease runs an abortive course. 

Infection by the same organism may occur 
after recovery from the effect of the infection. 

An attack of illness from infection, or intro¬ 
duction of toxin, produces permanent immun¬ 
ity to re-newed infection. 


We owe to Metchnikoff the first real at¬ 
tempt to explain active resistance of the body 


36 



against bacterial invasion. He developed the 
idea that certain cells normally possess the 
power to ingest, digest and destroy foreign 
matter and particles of dead tissue—the pro¬ 
cess of phagocytosis. 

Metchnikoff believed this to be the main, if 
not the only active defense agency of the body 
against injury by bacterial invasion. This was 
the foundation of the Metchnikoff Theory of 
Immunity. 

Metchnikoff states that the cells destroy the 
bacteria they incorporate by the enzymes (di¬ 
gestion) contained within their cytoplasm and 
produced by their own synthetic processes. If 
these enzymes are in the cells and the cells 
take up the bacteria, the latter are destroyed 
within the cells by the enzymes (digestion). 
If the enzymes are liberated by the destruc¬ 
tion of the cells (phagolysis), it is obvious 
that the tissue juices which have taken up the 
products of cellular disintegration become en¬ 
dowed with the solvent powers originally pos¬ 
sessed by the cells themselves. Thus Metchni- 
koff’s theory of phagocytosis no longer means 
only the incorporation of the bacteria by the 
cells, but includes all the reactions involved in 
the phenomena of immunity referable to chem¬ 
ical products formed by, and commonly con¬ 
tained within the cells and capable of acting 
upon the infective agents wherever they hap¬ 
pen to meet. It is believed that these enzymes 
destroy not only the bacteria but their products 
as well, so that immunity may mean either 


37 


destruction of bacteria or destruction of bac¬ 
terial products. (Immunization against bac¬ 
teria— immunization against bacterial prod¬ 
ucts.) 

Metchnikoff makes no distinction between 
the different classes of enzymes in these activ¬ 
ities. He and his followers consider it prob¬ 
able that the same agent destroys the bacteria 
and neutralizes their products. Thus, the ten¬ 
dency of this hypothesis is to regard the phe¬ 
nomena of immunity as simple chemical reac¬ 
tions. A common immunizing agent which is 
modified to greater activity against a specific 
disease. 

To sum up this theory, immunity does not 
always depend upon the same fundamental re¬ 
actions. It may depend upon the incorpora¬ 
tion and destruction of bacteria by body-cells, 
or upon the destructive action of the body 
juices into which the cellular enzymes have 
been discharged; or, when micro-organisms 
are not directly engaged in the production of 
disease, and the morbid changes result from 
the presence of a toxin, as in diphtheria and 
tetanus, immunity may depend upon the action 
of one of those enzymes on the poison intro¬ 
duced. According to this conception, there¬ 
fore, diphtheria antitoxin must protect either 
through the action of cellular enzymes which 
it contains already formed, or by stimulating 
the formation of protecting enzymes within 
the body. (McFarland in Cohen’s System of 
Physiologic Therapeutics.) Note the progres- 


38 


sive steps—not a disagreement but an advance¬ 
ment. Purely chemical—passive then active, 
with explanations of chemical action, then or¬ 
ganic chemical action. 

Ehrlich’s hypothesis is based on the mechan¬ 
ism of cellular nutrition, so that, as Welch 
has pointed out in his Huxley lecture on im¬ 
munity, the two theories (Metchnikoff and 
Ehrlich) have this view-point in common. 
Ehrlich’s conceives the structure of proto¬ 
plasm to be extremely complicated and char¬ 
acterized by enormous numbers of side-chains 
or groups of combining molecules—a concep¬ 
tion borrowed from the structural diagrams 
of organic chemistry. These side-chains, each 
being a definite molecular group, are supposed 
to have specific combining affinities. It is 
through the combination of particular molec¬ 
ular groups with appropriate groups in the 
tissue juices that cellular nutrition and metab¬ 
olism are supposed to be maintained. 

Prophylactic and therapeutic use of 

SERUMS AND VACCINES. 

The definitions formerly given of active and 
passive immunity should be recalled at this 
time; also of vaccines and serums. 

PROPHYLACTIC INJECTIONS 

A. Active Immunization —in which vaccina¬ 
tion and protective inoculations are in¬ 
cluded. 


39 


1. Inoculation of virulent organisms. 

(a) Inoculation of non-fatal doses 
(experimental work). 

(b) Inoculation of virulent organ¬ 
isms into tissues which have 
natural resistence (small-pox 
inoculation — unfavorable con¬ 
dition in the skin and small 
doses administrated). 

2. Injection of attenuated virus or toxin 
(attenuated by environment or pass¬ 
ing through animals)—Vaccination 
against small-pox. 

3. Injection of killed organisms (vaccin¬ 
ation against typhoid, plague and 
cholera). 

4. Injection of bacterial constituents. 

(a) Bacterial cell plasm (Koch’s T. 
R.). 

(b) Soluble bacterial products (bac¬ 
terial proteins—Koch’s O. T.). 

B. Passive Immunity —prophylactic injection 

of serum (diphtheria). 

C. Mixed Active and Passive Immunisation . 

Abortive Diphtheria. 

Varioloid. 

Tuberculosis. 

CURATIVE INJECTION 

A. Active Immunisation. 

1. Injection of killed organisms or tox¬ 
ins in small doses to hasten anti-body 


40 


formation (typhoid, etc.)—any dis¬ 
ease treated with vaccines. 

B. Passive Immunity. 

Anti-toxic serums (diphtheria). 

It appears that serums are more powerful 
in their action when nised as prophylactic 
agents than as curative agents. 

With serums, passive immunity is of short 
duration—in many instances not more than 
two or three weeks. However, they may be 
useful to combine with vaccines for active 
immunization, or following their use the body 
may develop active immunity. 

Time and amount of injection of serums is 
of importance whether for prophylactic or 
curative measures. 


41 


Post-Nasal 

Adenoids 


INFECTIOUS DISEASES 
OF THE RESPIRATORY 
TRACT 

DISEASE OF THE PHARYNX 

Acute, chronic, hypertrophic and atrophic 
processes occur in the pharynx and nasal 
mucosa. 

These hyperplastic lymphoid structures 
greatly affect the health, physical and mental 
development and future life of children. In 
all cases there is increased liability to acute 
coryza, pharyngitis, tonsillitis, laryngitis and 
bronchitis and added danger from attacks of 
measles, scarlet fever, whooping cough and 
diphtheria. If unrelieved, they may undergo 
atrophy as adult life approaches, usually leav¬ 
ing behind chronic naso-pharyngeal catarrh, 
high-arched palate, irregular teeth with maxil¬ 
lary protrusion and a deformed chest. Mouth 
breathing, nasal voice and snoring, and the evi¬ 
dent increase of respiratory obstruction in the 
dorsal recumbent position should call attention 
to these cases. Impaired hearing is extremely 
common, due to involvement of the Eustachian 
tube, and sinus infection is favored. 

These patients may present deformities of 
the face, mouth and nose; and the diseased 
pharynx is frequently the seat of chronic in¬ 
fections which impair the general health; such 
patients are poor surgical and anesthetic risks. 


42 


DISEASES OF THE TONSILS 

Tonsilitis, Acute Catarrhal —This common 
disease of young people is rare in infants and 
the elderly. 

Symptoms Onset rapid. 

A chill or chilliness, muscular and bone pain 
are followed by rapidly rising fever, with 
sore throat and dysphagia; the temperature 
reaches 103°-105° F., and the voice may be 
thick and nasal. The tonsils are swollen and 
dotted with a readily detachable exudate, 
which may become confluent, but tends to be 
limited to the tonsil. Great care should be 
taken to differentiate from diphtheria. 

Tonsilitis_ This differs from the preceding form chiefly 

Acute in the predominating involvement of one ton- 
Follicular s jp more violent onset, higher fever and pulse 
uppurative rate an( j g rea t e r prostration. The cervical 
glands are enlarged, salivary secretion is in¬ 
creased and within two or three days pus 
forms. Both tonsils may be involved; the pus 
may burrow with unexpected rapidity, and 
edema of the glottis may occur. Sequela- 
Chronic hypertrophied tonsils, common in 
childhood, continuing throughout life in many 
cases. 

This differs from the above in that the 
severity is less; the sequela are the same and 
quite as frequent. 

A sequela of the last two preceding condi¬ 
tions. It is one of the most important focal 
infections. 


Tonsilitis— 

Subacute 

Follicular 

Tonsilitis— 

Chronic 

Follicular 


43 


Laryngitis An acute catarrhal inflammation of the lar¬ 
ynx, which when due to infection is charac¬ 
terized by soreness of the throat, hoarseness 
or loss of voice, in adults; frequently a metal¬ 
lic cough. Course about three to twelve days. 

In children, because the glottis is narrower, 
the symptoms may be more serious. There is 
danger of laryngeal spasm (croup) and dan¬ 
ger of suffocation. 

This form is frequently associated with 
acute conditions of the mucous membranes of 
the pharynx, bronchi and nasal passages (cold 
in the throat, on the chest or in the head). 
The course of these infections is frequently 
from one to two weeks, which could probably 
be much reduced by the patient ceasing activ¬ 
ities and taking complete rest with the first ap¬ 
pearance of symptoms. The spread of these 
infections would probably be much reduced 
by such treatment. Repeated infections result 
in chronic inflammation of these tissues. 

Laryngitis Primarily, tuberculosis in this region is ex- 

TubercuIous treme ]y rare anc j usua py ? though not always, 
the lesion indicates an advanced pulmonary 
lesion. The symptoms are those of a persist¬ 
ent chronic laryngitis, hoarseness or aphonia 
being a marked and early symptom, and swal¬ 
lowing painful if there is epiglottic or pharyn¬ 
geal ulceration. The laryngeal mucous mem¬ 
brane is at first pale and later an ashy gray; 
the arytenoids show a pyriform swelling and 
the epiglottis is turban-shaped. The ulcers 
themselves are shallow and broad with gray 


44 


Etiology 


bases and irregular outlines, and the vocal 
cords usually appear “moth-eaten” from ulcer¬ 
ation. The tubercle bacilli can usually be 
demonstrated easily and this makes the diag¬ 
nosis positive. 

Tuberculous laryngitis frequently interferes 
with nutrition. The accompanying pulmon¬ 
ary condition tends to progress more rapidly. 
The patient’s resistance to trauma is low, heal¬ 
ing is frequently slow and there is a possibility 
of wounds about the mouth becoming infected. 
Extensive operations should be avoided. 

Tuberculous laryngitis is to be differentiated 
from syphilitic and cancerous affections of the 
larynx, with which it may be associated, and 
also tumors and paralysis due to nerve pres¬ 
sure and central lesions. 

DIPHTHERIA 

An acute infectious disease characterized 
by a fibrinous exudate, usually upon a mucous 
membrane, and with constitutional symptoms 
caused by the absorption of toxin. 

Caused by the Klebs-Loffler bacillus which 
may be communicated directly from the mem¬ 
brane or discharges, from nasal and buccal 
secretions of convalescents, from the throats 
of normal persons (“diphtheria carriers”) by 
infected articles and infected milk. It varies 
greatly in virulence, some strains causing no 
pathological effects. 


45 


Pathology 


Incubation 

Symptoms 


Treatment 


Compli¬ 

cations 

Sequelae 


The local lesion may be a simple catarrhal 
inflammation or a greenish or gray exudate 
containing pus, blood and epithelial cells. It 
is formed by necrosis of the epithelium and 
subsequent exudation into the necrotic tissue. 
The diphtheria bacilli live in the membrane. 

Associated lesions may be found in the kid¬ 
ney, liver, spleen or lymph nodes. There may 
be cardiac changes, broncho-pneumonia or de¬ 
generation of peripheral nerves, causing par¬ 
alysis. 

Two to seven days. 

Diphtheria onset frequently less rapid than 
acute catarrhal tonsilitis. Membrane appears 
on tonsils, spreads slowly, grayish white, dirty 
gray or yellowish; adherent, leaving bleeding 
surface. Cervical lymph node involved. Pos¬ 
itive diagnosis — finding diphtheria bacilli. 

Treatment—antitoxin early. Recovery may 
occur in a week but important sequelae may 
last indefinitely. The Schick test—may aid in 
determining what persons are susceptible to 
the disease, by giving a positive reaction. 
Diphtheria is a systemic disease; the mem¬ 
brane may form upon any mucous surface or 
wounds. 

Broncho-pneumonia, nephritis, hemorrhages 
from mucous membranes, urticarial or pur¬ 
puric eruptions. 

Paralysis, due to toxic neuritis and affecting 
most frequently the soft palate, less often the 
pharyngeal, laryngeal, occular, facial or res- 


46 


Diagnosis 


Prognosis 


Toxin- 

antitoxin, 


piratory muscles. Sudden death may occur 
due to neuritis of the cardiac nerve. 

Made with a certainty upon finding the bacil¬ 
lus in cultures. 

Good in mild cases. Mortality formerly 
about 40%. With antitoxin treatment 12%. 
If antitoxin is used early the mortality is much 
less than in cases in which it has been delayed. 

Pure cultures of diphtheria bacilli yield tox¬ 
in, which, injected into animals causes intox¬ 
ication and death. If small doses, insufficient 
to cause death, are injected at intervals, spe¬ 
cific diphtheria antitoxin is formed, which is 
contained in the serum of the blood. By the 
application of this principle, great quantities 
of diphtheria antitoxin are prepared, in horses, 
and used in the treatment of diphtheria, pro¬ 
ducing passive immunity in the individuals 
treated. 

The blood of many normal individuals con¬ 
tains diphtheria antitoxin in demonstrable 
quantities. This is stated to exist in sufficient 
quantities to afford protection to about 80% 
of the new born, 90% of adults and 50 to60% 
of children. 

Schick Test, 1-50 of the minimum tested 
lethel dose of diptheria toxin for a guinea pig, 
which weighs 250 grams, is diluted to make 
1-10 cc. of fluid. This is injected intracuta- 
neously and examined after twenty-four 
hours. Those who show a definite inflamma¬ 
tory reaction are susceptible to diphtheria. In 


47 


1909 Dr. Theobald Smith demonstrated that 
mixtures of toxins and antitoxins of diptheria 
bacilli, could be injected into guinea-pigs with¬ 
out harmful results, but that active immunity 
could be established which would last for sev¬ 
eral years. This combination has been stand¬ 
ardized and applied to the protection of man 
under the name of the Toxin-antitoxin treat¬ 
ment. The results of this prophylactic treat¬ 
ment have been summarized by the California 
State Board of Health. A brief summary of 
their conclusion is that: 

Toxin-antitoxin will prevent diphtheria. 

Toxin-antitoxin and antitoxin are two dif¬ 
ferent products. 

Toxin-antitoxin does not give protection 
against diphtheria immediately. Immunity 
against the disease is not acquired until at 
least three months after the administration of 
the toxin-antitoxin. It then gives protection 
for a long period of time, probably for life. 

Antitoxin is used for the treatment of diph¬ 
theria and for giving protection at once to per¬ 
sons who have been exposed to the disease. 
Antitoxin affords protection against diphtheria 
for a short period of time—two or three 
weeks. 

Toxin-antitoxin affords protection, probably, 
for life. It is harmless. It does not cause a 
sore on the arm. It produces little or no re¬ 
action in the individual to whom it is given. 
Persons who have been previously protected 
by means of toxin-antitoxin will not need 
antitoxin. 


48 


TUBERCULOSIS 


Tissue 

Changes 

and 

Resistance 


Tuberculosis is a disease resulting from the 
introduction of the tubercle bacillus, a minute 
vegetable micro-organism about 1-80,000 of an 
inch in thickness and about 1-6,000 to 1-16,000 
of an inch long, into the system. 

Tuberculosis is a communicable disease. 

Tuberculosis is a preventable disease. 

Tuberculosis is a curable disease. 

Tuberculosis, during the later stages, is 
known as consumption. 

When tubercle bacilli find lodgement in the 
tissue, an efifort is made for their destruction; 
this failing, an inflammatory condition devel¬ 
ops. They are surrounded by body fluids and 
cells which, in most instances, organize into 
fibroid masses or scar tissue, about the size of 
a pin head, encapsulating the tubercle bacilli, 
—a tubercle is formed. 


Tubercle Under these conditions the bacilli become 
a Healed more or less dormant. They are as seeds put 
Tuberculousaway for future planting; unless their environ- 
Lesion ment is changed they will not grow. The 
longer they remain in this condition the less 
readily will they grow. Scar, uninterfered 
with, matures with age,—it becomes harder, 
firmer, more resistent to physical and bacterial 
stresses. This small mass of scar encapsulat¬ 
ing tubercle bacilli is called a tubercle. It is 
a healed tuberculous lesion, an arrested tuber¬ 
culous focus, which, with time, may become a 
permanent arrestment or cure. Several of 


49 


Development 
of Resistance 


Infection 

Almost 

Universal 


these developing in close proximity form a 
tuberculous mass or scar. 

If the infection is received sufficiently slow¬ 
ly, this mass may be increased without pro¬ 
ducing symptoms, the tubercle bacilli gradu¬ 
ally losing their virulence and the scar acquir¬ 
ing greater density,—a degree of resistance is 
developed. Add to this the formation of anti¬ 
toxins, in an effort to neutralize toxins due to 
the presence of the tubercle bacilli, and we 
have developed that degree of resistance 
which, when attained, is sufficient to enable us 
to resist increasing amounts of infectious ma¬ 
terial, differing according to conditions in each 
individual. 

The virulence of the infectious organism, 
the quantity of infection received within a 
given time, and the resistance developed de¬ 
termines whether or not the health of the indi¬ 
vidual is appreciably influenced. 

Tubercle bacilli are met with by most per¬ 
sons in the earlier years of life, but under con¬ 
ditions which do not appreciably impair 
health. There is produced, however, tissue 
changes, — fibrosis or scar, — healed lesions. 
Frequently these are found in the lymph nodes 
of the hilus tissues of the chest, which finally 
become dense masses of fibrous tissue and 
later may undergo calcareous or caseous de¬ 
generation. It is these masses which are al¬ 
most universally seen in radiograms of the 
chest. These scars become firmer and more 


50 


resistant with age, and the encapsulated bacilli 
lose their virulence. 

Infection Infection exists, but without appreciable in- 
W^th^Health^^ ence on health. This condition is known as 
a latent tuberculous condition, which is almost 
universal. Such persons are not spoken of as 
tuberculous, but they do possess greater resist¬ 
ance against infection by tubercle bacilli from 
contact with persons suffering from tubercu¬ 
losis in an infectious condition than if they 
had not developed this scar. 

If the infection becomes greater than resist¬ 
ance, health is impaired. If during the first 
year of life the infection is sufficient to pro¬ 
duce symptoms in the individual, death gener¬ 
ally results, because there has been insufficient 
time to develop adequate resistance. If symp¬ 
toms develop later the extension of the lesions 
may cease, — fibrosis or scar develop, — the 
Manner of same general conditions developing as occurred 
Arrestment in the formation of the smaller mass or tu¬ 
bercle. An arrestment has occurred through 
the formation of scar. Much of this scar tis¬ 
sue is permanent. Its presence is a factor in 
maintaining the future resistance of the indi¬ 
vidual against infection. In many cases the 
existence of the tuberculous infection may not 
be known to be a factor in the “under-par” 
child, in whom other infections exist, the prop¬ 
er treatment of which restores the child to 
health, but the tuberculous foci continue to 
exist in a latent form. 

While these healed foci aid in maintaining 


51 


Mechanical 

Stresses 


Bacterial 

Stresses 


General 

Stresses 


the resistance against infection, that resist¬ 
ance is not complete or permanent. It may be 
overcome by an overwhelming amount of in¬ 
fection. Following recovery from this child¬ 
hood infection, most frequently the develop¬ 
ment of an active tuberculous condition is due 
to a re-activation of a healed lesion. 

STRESSES 

This is brought about by stresses. These 
stresses may be (a) mechanical, (b) bacterial, 
(c) general. 

Are more frequently strains through mus¬ 
cular action which involves scar tissue, over¬ 
exertion or continuous work leading to gener¬ 
al, prolonged exhaustion. 

Are those infections which act directly upon 
the scar or bring about degenerative changes, 
and those which reduce resistance. 

Include other factors which reduce resist¬ 
ance, i. e., unsanitary surroundings, under¬ 
nourishment, excesses of all kinds, whether 
overwork or play, etc. 

Mechanical and bacterial stresses frequently 
produce inflammation of the latent infected 
foci, thus changing the environment to a con¬ 
dition unfavorable for the growth of the tu¬ 
bercle bacilli to a favorable one. In most in¬ 
stances this is again recovered from by pro¬ 
cesses similar to that which checked the for¬ 
mer activity. This is repeated many times, in 
most cases, before symptoms and signs are 
sufficient that a diagnosis of tuberculosis is 


(2 


made. The relief from removable stresses is 
of greatest importance in aiding the body to 
check the progress of the infection and hold it 
in check,—formation of new scar and allow¬ 
ing the scar to mature. 

Pathological The pathological history of tuberculosis may 
History b e sumrnar i ze d as follows: 

(a) Childhood infection healed by forma¬ 
tion of scar,—permanent infected foci. 

(b) Reactivation of these foci through 
stresses or pathological changes. 

(c) Arrestment of the reactivated condi¬ 
tion, which may be permanent—re¬ 
covery—or temporary and followed 
by destructive changes. 

(d) The relief from bacterial toxins, pro¬ 
duced by associated infections, is of 
great importance. It is through the 
removal of some of these foci that the 
work of the dentist becomes of great 
value, as well as in aiding nutrition, 
through providing means for the more 
thorough mastication of food. 

When we consider the prevalence of latent 
foci of tuberculous infection in the lungs, the 
frequency and extent of the infected foci of 
the investing tissues of the teeth by pus pro¬ 
ducing organisms and the channels of commu¬ 
nication between these areas, it is not difficult 
to appreciate the possibility of influence of 
these associated infections upon the pulmonary 
tuberculous foci. 


53 


INFLUENCE OF FOCAL INFECTION 
ON THE TUBERCULOUS 

Influence When we consider the barriers of the tis- 
of . sues, mechanical and chemical, which serve as 
Operations a protection, and added to these, the compara- 
Tuber e c»lou.tively slow development of activity of the 
tuberculous focus, then we may appreciate the 
apparent infrequency with which this reactiv¬ 
ation occurs. However, the constant absorp¬ 
tion of the toxins from these foci lower re¬ 
sistance and, if a large amount of the infec¬ 
tious material, other than tuberculous, is 
thrown into the system through operative pro¬ 
cedure, the condition becomes favorable for 
reactivation of a latent tuberculous focus, or 
may materially interfere with the favorable 
progress of an existing active process toward 
recovery. I have not had an opportunity to 
collect data in regard to this, but am more and 
more impressed with the importance of these 
conditions as I have greater opportunity for 
observation. 

I also am more and more impressed with 
the necessity for careful consideration of 
treatment of these infected foci. In infected 
tissue the treatment of only a small area at 
one sitting is important and the least possible 
amount of trauma should be produced. 

Allow time for the patient to recover com¬ 
pletely from the results of the increased in¬ 
fection between treatments. 


54 


Limit 

Operative 

Procedure 


Decrease in 
Tuberculosis 


Extract only one or two teeth at one sitting, 
allowing time for recovery. Frequently five 
days or more should be allowed between oper¬ 
ations. The danger may be reduced by treat¬ 
ment of the infected foci before extracting. 

The mortality from tuberculosis has de¬ 
creased from about two hundred per hundred 
thousand to about one hundred per hundred 
thousand population in the registration area 
of the United States during the last twenty 
years. The decrease has included all classes 
excepting girls from the age of fifteen to 
twenty years. In this class there has been an 
increase in the death rate of about seven per 
cent. 

From intensive work which has been done 
in selected districts, as Farmingham, Mass., it 
seems probable that through co-operative ef¬ 
forts the death rate may be much further 
reduced. 


55 












THE ADMINISTRATION 
OF VACCINES 


THE ADMINISTRATION 
OF VACCINES 

The most frequent errors committed in ad¬ 
ministration of vaccines are the giving of too 
large doses and repeating at too short intervals. 
In the hypodermic administration of the vac¬ 
cines more commonly used prophylactically 
and therapeutically, the following suggestions 
are valuable guides for the control of doses. 

If there should be no redness at the site of 
injection, the next injection may be adminis¬ 
tered on the fifth day following, increased by 
one-half to double the former dose. Continue 
the administration in this manner unless local 
reaction appears. If redness the size of a sil¬ 
ver half dollar occurs, which lasts more than 
forty-eight hours, I would repeat the former 
dose; should the area of redness be greater 
than this, or persist longer, I would suggest 
waiting forty-eight hours after all redness has 
disappeared, then administer one-half the for¬ 
mer dose. 

There are exceptions in the use of typhoid, 
small-pox and others for which special direc¬ 
tions are given with each vaccine. 

The vaccine against the bacteria which most 
frequently produce “colds” in most cases may 
be begun with an initial adult dose of fifty 
million bacteria. Persons who are known to 
be especially sensitive should be started with 
smaller doses, even as low as ten million. 


59 


Dose of 
Tuberculin 


Persons who have taken vaccines, and whose 
resistance is known, may be given from one 
hundred to two hundred million, followed by 
increasing doses. The increase may be pro¬ 
portionate to the initial dose, that is, in the 
person who is very sensitive and develops a 
moderate degree of local reaction with a dose 
of ten million, the increase should not exceed 
ten million, while an individual whose initial 
dose is fifty million or more may be increased 
fifty million. 

The initial dose of vaccine against tubercu¬ 
losis should be governed by a cutaneous test. 
Due consideration should be given to the tis¬ 
sues in which the focus exists, to degree of 
activity, also its extent; the patient with a 
small focus recently re-activated will be more 
likely to be sensitive to the vaccines. Patients 
with involvement of tissues such as the eye, 
meninges, lymph nodes, joints and bones will, 
all other things being equal, be more sensitive, 
and in the order named, than the softer tissues. 
The pulmonary tissues possess greater toler¬ 
ance to vaccines than do most of the tissues 
in which tuberculosis is frequently found. 

Based upon these suggestions, the initial 
dose of tuberculin, or vaccine prepared from 
tubercle bacilli, may vary from one billionth of 
a milligram (0.000,000,001 mg.) in specially 
sensitive cases to one thousandth milligram 
(0.001 mg.). 

Sodium succinate manifests a selective ac¬ 
tion for tuberculous tissues and acts very 


60 


Sodium 

Succinate 


much as does a vaccine. In its administration 
the suggestions made in regard to vaccines 
apply. Reactions due to its use are apparently 
less severe and less prolonged than with tuber¬ 
culin. For this reason the writer frequently 
begins treatment of hypersensitive cases by 
the use of sodium succinate in beginning doses 
of about 0.001 mg. The patient whose toler¬ 
ance to sodium succinate reaches 1. mg. will 
as a rule tolerate 0.001 mg. of tuberculosis 
vaccine. From a practical standpoint in the 
treatment of tuberculous conditions, a dose 
exceeding five mg. of tuberculosis vaccine or 
ten mg. of sodium succinate is ordinarily not 
required. 

In the use of these vaccines, however, we 
should always bear in mind that it is the result 
and not a specific dose which is needed. Fre¬ 
quently very sensitive patients make more 
rapid progress on small doses suited to their 
condition than the more tolerant patient using 
correspondingly larger doses. 


ci 


INFLUENCE OF FOCAL 
INFECTIONS UPON 
THE HEART 

Endocarditis Among well recognized and more important 
results of focal infection of the peridental tis¬ 
sues is a painful condition of the tendons of 
the muscles and joints which is frequently 
spoken of as muscular rheumatism, and the 
more acute inflammation of the tissue of 
joints, inflammatory rheumatism. This is fre¬ 
quently accompanied by endocarditis with the 
resulting changes in function of the valves of 
the heart. The result of this condition may be 
either obstruction to the free passage of the 
blood through the valves, or insufficient clos¬ 
ure of the valves allowing regurgitation of the 
blood backward through the valves against 
the blood stream. As a result of this there is 
hypertrophy of the muscular tissue of the 
heart which produces a measure of compen¬ 
sation for the changes in the valves. As a 
result of the changed condition of the valves, 
vegetations are produced on the valves which, 
when freed, form emboli, which find their 
way to the different parts of the body with 
greater or less unfavorable results. If one of 
the more important arteries of the brain is 
reached by these emboli, cerebral apoplexy 
with the resulting paralysis or death ensues. 

Ulcers of the stomach and intestinal tract, 
and infections of the gall-bladder and other 


62 


abdominal viscera have been attributed to in¬ 
fections from the nose, throat and peridental 
tissues. 

The work of Rosenow of the Mayo Clinics, 
confirmed by others, is of great interest in 
showing the selection of tissue by given strains 
of organisms from foci of chronic infections. 
A group of 666 animals were infected with 
organisms from foci of infections from pa¬ 
tients suffering from secondary lesions in dif¬ 
ferent tissues. The animals developed infec¬ 
tions in corresponding tissues in an average of 
about 75%. 

During the past few years the writer has 
frequently had occasion to make examinations 
of adolescents who have been unable to satis¬ 
factorily perform the prescribed gymnasium 
work in the schools. 

Most of these children had been regarded 
as lacking in energy; they may have been 
studious, but had avoided amusements which 
required physical exercise. Upon fluoroscopic 
and radiographic examination I was impressed 
with the frequency of the occurence of the 
Drop Heart “d ro P heart ” an elongated and narrowed con¬ 
dition of the heart. 

Green in Medical Diagnosis states that this 
is one manifestation of a general visceroptosis, 
and may or may not constitute its dominant 
feature clinically and anatomically; that no ill 
health may necessarily develop as the result, 
but that symptoms tend to develop under con¬ 
ditions of impaired nutrition. 


63 


Myocardial 

Changes 


The heart, by reason of the constant demand 
made upon its musculature and its sensitive¬ 
ness to toxins, acute and chronic, is prone to 
manifest symptoms. During observation of 
the young persons above referred to I was 
quite impressed with the frequency with which 
I found the existence of chronically infected 
foci. Careful examination has revealed such 
infection in all cases thus far examined. 

When we consider the prevalence of chronic 
infections which fail to manifest local symp¬ 
toms and which for this reason are not dis¬ 
covered early, and the influence of these 
chronic infections upon the general muscular 
system, we may well consider whether or not 
these infections may have been the cause of 
the changed conditions of these organs, rather 
than being due to poor nourishment and de¬ 
velopment. 

When symptoms have been manifest, espe¬ 
cially of the heart, they have improved with 
the care of the infection and recurred with 
the development of greater infection, suffic¬ 
iently frequently to convince me that a causal 
relation exists. 

The evidence of physical weakness of the 
heart is frequently manifest by low systolic 
and pulse pressures. If these conditions are 
observed when the patient is in the recumbent 
position, a markedly decreased pulse pressure 
occurs upon rising to a standing position in 
cases of marked myocardial weakness. I have 
observed this symptom improve or grow 


64 



FIG. 1.—Young woman of slender build. 

Radiographs taken during forced inspiration. 

Upper cardiac outline (1), of normal heart, is of a person about 
the same age and weight, short, stout build, applied on this chest; 
this gives contrast with middle outline (2), indicating normal cardiac 
outline of this chest; note width of intercostal spaces. The dotted 
line (3) indicates stereoscopic cardiac outline, a condition frequently 
met with in the underweight adolescent. This condition has fre¬ 
quently been associated with foci of chronic infection of the investing 
tissues of the teeth, the tonsils or nasal passages and sinuses; not 
infrequently more than one region is infected. 

In this type of heart the action of both ventricles is plainly 
visible in the fluoroscope, in the lower portion of the shadow, contract¬ 
ing and dilating at the same time, while the action of the auricles are 
observed toward the top. It is the change in the ventricles which 
take greatest part in these myocardial changes. As time goes on the 
tendency of this type of heart is to yield to strain and we may observe 
the gradual dilation of the lower portion of the ventricles, more fre¬ 
quently the left. 
























* 



















* 





































FIG. 2—Radiographs taken during forced inspiration. 

Long standing infection of peridental tissues. Had been in 
good clinical health until past few months, when ill defined symptoms 
of toxic condition began to be manifest. Following the extraction of 
four teeth which were surrounded by extensive chronic infection, pain 
developed in the precordial region, with slight extension down the left 
arm, no cardiac murmurs. 

Blood pressure, second and third phases, 70-86. 







FIG. 3—Radiograph taken during forced inspiration. 

Solid line (1) within normal limits of stereoscopic cardiac outline. 
History of moderate degree of chronic focal infection. Observe dropping 
and narrowing of the actual stereoscopic outline. Recently signs of 
mitral insufficiency were detected. Observe the apparent beginning of 
ventricular hypertrophy. 

Blood pressure, reclining, second and third stages, 90-110, standing, 
about one minute after rising 80-110. 











FIG. 4—Observe the condition in advanced cases of mitral insufficiency. 
Reproduced by courtesy of P. Blakiston and Sons, from Medical Diag¬ 
nosis, Green. White lines by author. 





FIG. 5—Male, age 61. 

Radiograph taken during forced inspiration. 

History of long standing focal infections of tonsils and peridental 
tissues. Gave history of attacks of angina pectoris. Examination, 
including electrocardigraphic examination by Dr. Stanley Granger 
found condition favorable for this condition. No cardiac murmurs. 
Blood pressure, second and third stages reading; Reclining, 110-160, 
standing 100-160. 

Patient later died of angina pectoris. 
















fig. 6—Male, age 66. 

Radiograph taken during full inspiration. 

Aneurism of Aorta. 

Patient had recently noticed an uneasy sensation in his chest, 
accompanied by an increasingly annoying spasmodic cough. Physical 
signs of thoracic aneurism. Blood Wassermann, four plus. Syphilic 
aortitis is a frequent cause of aortic aneurism. 







Angina 

Pectoris 


worse with the decrease or increase of inten¬ 
sity of focal infections. All persons suffering 
from chronic focal infections do not suffer 
from these changes, but certainly many who 
suffer from this type of myocardial change, 
without valvular lesions, have foci of chronic 
infections of the nasal cavities and accessory 
sinuses, the tonsils or investing tissues of the 
teeth. These tissues are subject to infection 
by the same infectious organisms; what may 
be said of the general results of infection of 
one tissue may be said of the others. 

Hearts suffering from the foregoing de¬ 
scribed conditions are easily subject to greater 
or less dilatation through physical stress, with 
the accompanying unpleasant symptoms. In 
some of these persons who have been contin¬ 
uously only slightly overworked a slight degree 
of chronic dilatation occurs; with increasing 
shortness of breath even to the condition of 
fainting upon moderately increased exertion. 

With relief from infection, rest, and later 
properly graduated exercise improvement 
often occurs. 

In the few cases of Angina Pectoris which 
I have seen since these observations have been 
in progress, each has had extensive focal in¬ 
fection with radiographic shadows of the type 
seen in illustration, without valvular murmurs. 

If even a small portion of the cases suffer¬ 
ing from the foregoing conditions are due to 
the foci of infection described, the importance 


65 


Angina 

Pectoris 


of the painstaking dentist and nose and throat 
specialist is emphasized. 

is a paroxysmal neurosis, generally associ¬ 
ated with disease of the heart and aorta, fre¬ 
quently accompanied by circulatory disturb¬ 
ance, with changes in the coronary arteries, 
which interferes with cardiac nutrition. It is 
characterized by acute attacks of agonizing 
pain in the region of the heart, extending into 
the neck, down the arms, especially the left, 
on the inside, with a feeling of impending 
death. It frequently accompanies fatty mus¬ 
cular degeneration, arterio-sclerosis, syphilitic 
or chronic streptococcic infections. 

The prognosis is grave, many patients 
finally dying in an attack. Paroxysms and 
death are often precipitated by excessive exer¬ 
cise or mental excitement. They are poor 
operative risks and take anesthetics poorly. 


66 


OTHER INFECTIOUS 
CONDITIONS 






Infectious 

Disease 


Local 

Symptoms 


OTHER INFECTIOUS 
CONDITIONS 

A few of the more important infectious dis¬ 
eases will be considered only in so far as to 
aid in their recognition, and some of the more 
important sequelae. According to their appear¬ 
ance in communities infectious diseases may 
be (1) Sporadic, occurring in isolated and 
scattered cases; (2) Endemic, appearing in a 
number of cases, but confined to certain local¬ 
ities; (3) Epidemic, affecting a large number 
of persons simultaneously and spreading rap¬ 
idly to other localities. 

The results of infections are shown by local 
or constitutional symptoms or both. The con¬ 
stitutional symptoms usually include those of 
fever , which may be sthenic or asthenic. 
Sthenic Fever symptoms are a hot, dry, flushed 
skin, increased pulse and respiration attended 
by restlessness. There is thirst, digestive dis¬ 
turbance and headache. 

Asthenic Fever symptoms are a damp, clam¬ 
my skin, dry mouth, coated tongue, weak pulse, 
shallow respiration, stupor or delirium. 

May include changes in the skin, which may 
appear as 

1. Macules or patches, as a freckle; 

2. Papule, a circumscribed elevation, as a 
pimple; 

3. Tubercules or large papules; 

69 


Scarlet 

Fever 


Etiology 


Pathology 


4. Vesicles or elevations filled with serous 
fluid; 

5. Pustules or elevations filled with pus; 

6. Blebs or bullae—elevations of the horny 
layer and in size much larger than a 
vesicle. They are filled with a serous 
fluid. 

There are many lesions due to the change of 
the primary lesion, as scales, crusts, excoria¬ 
tions, fissures, ulcers, scars and pigmentations. 

ACUTE INFECTIOUS DISEASES 

If persons suffering from acute infectious 
diseases have come to your office by means 
of a public conveyance, they should, if possi¬ 
ble, be returned by private or special con¬ 
veyance. Frequently this can be arranged 
for through the health department. 

An acut infectious disease characterized by 
sore throat and a diffuse scarlet eruption. 
One attack does not necessarily protect from 
others. 

An unknown micro-organism, possibly a 
modified streptococcus. It may be conveyed 
by discharges from the mucous membranes, 
clothing, bedding, books, toys or domestic 
pets coming in contact with the patient. Scar¬ 
let fever may be carried in food, particularly 
milk. 

An inflammation of tonsils, pharynx and 
larynx, which is usually catarrhal, but may 
be membranous or gangrenous. This process 


70 


Incubation 

Symptoms 


Malignant 

Scarlet 

Fever 

Compli¬ 

cations 


frequently extends to the nose or ear. Inflam¬ 
mation of the skin of variable intensity, re¬ 
sulting in the death of the epidermis, which 
is thrown off in the desquamation. There is 
general hyperplasia of lymphoid tissue. 
Lesions due to mixed infections may occur 
in the heart, lungs, liver or spleen. 

One to seven days. 

Soreness of the throat, usually vomiting, 
rapid pulse, rapid rise of temperature to 104° 
or 105°, diffuse scarlet rash usually appearing 
inside of twenty-four hours on the neck and 
chest and rapidly spreading over the body. 
The tongue is swollen and coated, with a red 
margin. Later the tongue is red and rough 
with prominent papillae—“the strawberry 
tongue.” 

may occur with a very high fever and hem¬ 
orrhage into the skin and mucous membranes. 
Death usually occurs. 

Nephritis, arthritis, endocarditis, pericar¬ 
ditis, myocarditis, pleurisy, otitis media, sup¬ 
puration of lymph glands and changes in the 
nervous system, such as chorea. 


The sudden onset, eruption, throat symp¬ 
toms, the tongue, and desquamation. It dif¬ 
fers from measles in the absence of coryza 
and buccal spots. Diptheria told by micro¬ 
scopic examination of throat cultures. 


71 


Etiology 

Pathology 

Incubation 

Symptoms 


Compli¬ 

cations 

Diagnosis 


MEASLES 

Measles is an acute infectious disease char¬ 
acterized by initial coryza and a rapidly 
spreading blotchy eruption. 

An unknown micro-organism. Only a short 
exposure is necessary to communicate the dis¬ 
ease and it is most contagious in the catarrhal 
stage. 

No characteristic lesions. There may be 
changes in the lungs, kidneys or lymph nodes. 

Usually two weeks. 

Chilly feeling, coryza, redness of eyes and 
lids, photophobia, cough, fever from 102° to 
104°. The patient may complain of a sore 
throat and congestion is seen. Buccal spots 
or Koplik’s spots appear as bluish white spots 
surrounded by red areolae, and are found in 
the mucous membrane of the cheeks. The 
eruption begins about the fourth day, usually 
on the forehead, as small red papules and 
extends over the body taking the form of 
crescentic reddish blotches. 

Hemorrhagic measles may occur with severe 
invasion, characterized by hemorrhages on 
the mucous membranes and usually ending 
fatally. 

Broncho-pneumonia, purulent conjunctivitis, 
otitis media, enteritis, nephritis, pertusis and 
tuberculosis. 

From scarlet fever by milder onset and 
blotchy rash. From German measles by care- 


72 


Etiology 

Incubation 

Symptoms 

Compli¬ 

cations 

Diagnosis 


Etiology 


Pathology 


ful observation and milder symptoms. From 
drug eruptions by lack of catarrhal symptoms 
in the latter. 

GERMAN MEASLES (Rubella) 

Rubella is an infectious disease resembling 
both scarlet fever and measles. 

Unknown; occurs in epidemics. 

Ten to twelve days. 

Chilliness, slight fever, coryza and macular 
eruption on the throat. In twenty-four hours 
it covers the body. The eruption is brighter 
than measles and less crescentic. 

Are rare. 

By slight constitutional symptoms, little or 
no fever, color of rash and early enlargement 
of cervical lymph glands. 

SMALL-POX (Variola) 

Small-pox is an acute infectious disease 
characterized by an eruption which is suc¬ 
cessively papular, vesicular, pustular and 
crusty, and by a peculiar febrile reaction. 

An unknown poison in the pustules or 
crusts. One attack generally confers immun¬ 
ity for life. Severe forms may be contracted 
from mild forms. The disease is contagious 
from the beginning, and may be carried by 
one who is not himself infected. 

Pustules on the skin which leave a scar only 
if the true skin has been involved. There 


73 


Varieties 

Incubation 

Variola 

Symptoms 


Confluent 

Hemor¬ 

rhagic 

Varioloid 


may be a diffuse suppuration of the skin, 
hemorrhages on skin or mucous membranes 
and degeneration of spleen, liver or kidneys. 

1. Variola. 

2. Variola hemorrhagica. 

3. Varioloid. 

Ten to fourteen days. 

Chill, severe pain in lumbar region and in 
extremities, vomiting, temperature 103°-104°. 
An erythematous or macular rash begins on 
lower abdomen, inner surface of thighs and 
axillae. There are eruptions of small red 
papules on the forehead on the fourth day. 
These spread rapidly over the face, trunk, 
extremities and mucous membrane, the palms 
of the hands and soles of the feet. The erup¬ 
tion is most marked on the face. With the 
eruption the temperature and the constitu¬ 
tional symptoms subside. The papules be¬ 
come vesicles with clear fluid contents and 
later pustules. With the formation of pust¬ 
ules the temperature rises again and the con¬ 
stitutional symptoms return. The pustules 
become umbilicated, dry gradually, forming 
crusts, which fall off, leaving a scar. 

forms are seen when the papules are confluent 
and all symptoms are more severe. 

Punctate hemorrhages appear on the skin, 
mouth, internally or into pustules. 

Small-pox modified by vaccination. The 
invasion is sudden and severe, but the pus¬ 
tules are scanty and mature rapidly. There 


74 


Compli¬ 

cations 

Prognosis 

Diagnosis 


Etiology 

Incubation 

Symptoms 

Compli¬ 

cations 


is an early disappearance of constitutional 
symptoms. 

Edema of the glottis, broncho-pneumonia, 
pleurisy. Later boils, abscesses, ulcerative eye 
diseases and otitis media. 

High mortality to those unprotected by 
vaccination. Different epidemics differ great¬ 
ly in virulence. A mild epidemic may sud¬ 
denly become very virulent. 

Characteristic eruption and severe consti¬ 
tutional symptoms. An eruption on palms of 
hands and soles of feet during course of an 
acute disease is of great diagnostic import¬ 
ance. 

Small-pox may be almost entirely elimi¬ 
nated by vaccination. 

VARICELLA (Chicken Pox) 

Chicken Pox is an acute infectious disease 
characterized by a vesicular eruption. 

Unknown cause. Is not related to small¬ 
pox. 

Ten to fifteen days. 

Slight fever, chilly sensation, pain in back 
and extremities. The eruption appears in 
twenty-four hours as papules. These soon 
become vesicles and then pustules. The erup¬ 
tion appears in successive crops on trunk or 
face, and all stages of development are often 
seen at once, 
are rare. 


75 


Diagnosis 


Etiology 

Pathology 

Incubation 

Symptoms 


Compli* 

cations 

and 

Sequelae 

Diagnosis 


The symptoms are less severe than small¬ 
pox, the fever runs a different course, and 
the eruption is in crops. Severe cases may 
be difficut to differentiate from small-pox. 

WHOOPING COUGH (Pertussis) 

Pertussis is an infectious disease charac¬ 
terized by a paroxysmal cough followed by 
a deep sonorous inspiration, the “whoop.” 

The exciting cause is the bacillus pertussis, 
found in the sputum. The disease is epidemic 
and often associated with other epidemics, 
one of which is measles. 

No characteristic lesions. 

Seven to ten days. 

It begins with catarrhal symptoms, which 
last about ten days. The cough gradually be¬ 
comes worse until a paroxysmal stage with 
the “whoop” is developed, which frequently 
continues for several weeks. The attack con¬ 
sists of a number of forceful expiratory 
coughs, followed by a long inspiration through 
the contracted glottis, which causes the shrill 
whoop. During the attack the face is cyanotic 
and the paroxysm may end in vomiting. There 
is a marked lymphocytosis. 

Hemorrhages into the skin, mucous mem¬ 
brane, conjunctiva or brain; broncho-pneu¬ 
monia, emphysema and tuberculosis. 

The “whoop” is characteristic. 


76 


MUMPS OR EPIDEMIC PAROTITIS 

Mumps is an acute infectious disease char¬ 
acterized by an inflammation of one or both 
parotid glands, or of the testis, or ovaries or 
breasts. 

Etiology Unknown. 

Incubation Two or three weeks. 

Symptoms The onse t i s with slight fever and pain 
below the ear, swelling of the parotid gland 
and difficulty in swallowing. Other salivary 
glands may be involved. Severe constitu¬ 
tional symptoms are rare. 

Complica- Orchitis is common in the adult male. 

cations andOvaritis and mastitis may occur in women. 

Sequelae 

Diagnosis The swelling of mumps may be differen¬ 

tiated from the swelling of cervical lymph 
nodes by the fact that the swelling of the 
parotid gland is in front of and behind the 
ear, the lobe of which is raised and everted. 

ACUTE POLIOMYELITIS—(Infantile 
Paralysis) 

Infantile Paralysis is an acute epidemic or 
sporadic infection involving the anterior horns 
of the spinal cord. 

Etiology A micro-organism transmitted through the 

secretions of an infected person’s nose and 
throat and probably through “carriers” who 
are themselves immune. Children from one 
to five years old are most often attacked. 


77 


Pathology 

Incubation 

Symptoms 


Diagnosis 


Etiology 


Inflammation in the anterior horns of the 
spinal cord or higher nerve centers which may 
go on to degenerative changes. 

Two to fourteen days. 

Fever, digestive disturbances, listlessness, 
drowsiness; there may be retention of urine 
and sensitiveness of the skin, or the child may 
suddenly awake with paralysis, which is 
frequently permanent. 

By the presence of an epidemic. Paralysis 
accompanying the above symptoms. Lumbar 
puncture. 

Isolation of patients and hearty co-opera¬ 
tion with the health authorities is necessary 
for the control of Acute Poliomyelitis. 

TYPHOID FEVER 

Typhoid fever is an infectious disease char¬ 
acterized by hyperplasia and ulceration of the 
intestinal lymph nodes. 

It is caused by the bacillus typhosus, in¬ 
troduced into the intestinal canal by contami¬ 
nated drinking water, milk, ice or other food. 
It is carried by flies, on the hands, dishes, 
etc. 

Typhoid fever is not a disease that the 
dentist will be called upon to diagnose, but is 
one of the many diseases to which he must 
give his attention both as a citizen and as a 
medical specialist. He should help in mat¬ 
ters of education and in laws controlling 
drinking water, food supplies and in the care 
of the contagious individual. 


78 


Black 

Plague 


Typhoid fever can he controled by either 
sanitation or vaccination. Vaccination should 
be administered to persons going into places 
where there is doubt as regards the sanitary 
conditions. Also by those zvho have the care 
of typhoid patients. 

TYPHUS FEVER 

Typhus fever is an acute infectious disease 
characterized by a severe general toxemia. It 
is transmitted by the bite of the body louse. 
The disease is found in insanitary camps, 
jails and ships. It is occasionally brought 
into California from Mexico. At various 
times in the history of the world this disease 
has been epidemic, but modern hygiene has 
it under control in all enlightened communi¬ 
ties. 

PLAGUE 

By the term “Plague,” when not qualified, 
or by the terms “Black Plague,” is meant an 
acute infectious disease which occurs in two 
forms: 

a. Bubonic Plague. 

b. Pneumonic Plague. 

The more common form is bubonic plague, 
which is manifested by symptoms common 
to severe, acute infectious diseases, such symp¬ 
toms being high fever, great prostration, ac¬ 
companied by inflammation and swelling of 
the lymph nodes, which may easily be felt in 
the axilla, groin and neck. The disease runs a 


79 


rapidly fatal course in the large majority of 
cases. 

Pneumonic plague develops in the lungs, 
and shows symptoms of a very acute pneu¬ 
monia, which is fatal in from two to five days 
in the majority of cases. 

Both forms of plague are due to the same 
organism—the bacillus pestis, the difference 
in the two forms being whether or not the 
lungs become infected. 

Plague is a disease of rodents, the two of 
greatest importance to the human family be¬ 
ing the rat, which is very susceptible to the 
disease, and the ground squirrel, which comes 
near enough to the dwelling of man to be in 
intimate contact with the rat, infecting it with 
the plague. The rat in turn carries the dis¬ 
ease to the abode of man. Thus the ground 
squirrel is a real source of danger to man. 

Plague is transmitted to man from the 
rodent by means of a species of flea which 
lives on rodents, and most frequently on rats. 
When the animal dies of plague, the fleas 
leave the dead body, carrying with them some 
of the blood of the animal, and a man bitten 
by such fleas becomes inoculated with the 
germs of the disease, providing the site of the 
bite is scratched. 

This most frequently produces bubonic 
plague, which is not transmitted direct from 
man to man, but only through the medium 
of the germ-laden flea, because the plague 
bacilli are not thrown off—an open sore is 


80 


not formed. However, if the disease attacks 
the lungs, producing pneumonic plague, the 
bacilli are thrown off in the expectoration and 
are received by those who come in contact 
with them, and such persons develop puen- 
monic plague, which spreads very rapidly. 

Plague was probably first introduced into 
the United States in 1898 from the Hawaiian 
Islands by infected rats carried in ships into 
San Francisco. (Kellogg, Journal American 
Association, May 10, 1900.) Following this, 
sporadic cases among men and rats developed, 
most frequently in the bay district. 

In August, 1919, in Oakland, a case of 
bubonic plague was reported, which later de¬ 
veloped into pneumonic plague. From this 
one case twelve contacts developed pneumonic 
plague, making a total of thirteen cases, of 
which twelve died. (Kellogg, Americal Jour¬ 
nal of Public Health, July 20, 1920.) 

This is the first pneumonic plague known 
to have occurred in the United States. 
Prompt measures were taken and the disease 
was brought under control. Had it not been 
promptly checked, we cannot estimate what 
the result might have been. 

Contrast the above mentioned situation with 
conditions in Manchuria, where pneumonic 
plague developed during the winter of 1910- 
1911. Fifty thousand persons died within 
three months. Our papers related the hor¬ 
rors, the burning of bodies in the streets, it 
being impossible to dispose of them in any 


Infection 


Incubation 

Period 


other manner. This has been related to the 
writer by an eye witness. 

Plague has more recently appeared in some 
of the southern ports of the United States. 

Rat extermination is the keynote to the con¬ 
trol of the disease, and added to our problem 
is also the extermination of the ground squir¬ 
rel, in order to insure security from this men¬ 
ace to humanity. To bring this about we 
must maintain and earnestly cooperate with 
our Department of Health. A district in 
which infection has become extensive among 
the rodents will probably be continuously in¬ 
fected and will require the service of compe¬ 
tent health authorities. 

RABIES—Hydrophobia 

An acute infectious disease transmitted 
most frequently to man by the bite of rabid 
animals, more frequently the dog. 

The infection is in the negri bodies, which 
are found in the nerve cells of the central 
nervous system. 

The incubation period varies greatly from 
a few days to several months. The period 
of incubation is apt to be shorter, and the 
symptoms more severe, the nearer the head 
the wound occurs. The earlier symptoms are 
irritation at site of wound, anxiety, headache, 
irritability, and other symptoms common to 
acute inflammation of the central nervous 
system, terminating in spasms most distress¬ 
ing in character, which terminate in death. 


82 


Prophylactic A person being bitten, the wound should 
Treatment excise^ or if possible a ligature may be 
applied above the wound. Nitric acid should 
be applied as soon as possible and the wound 
thoroughly cauterized. (Carbolic and other 
acids are less effective.) This may be fol¬ 
lowed by the application of a solution of 
Sodium Bicarbonate (saturated), washed in 
sterile water and a dry dressing applied. 
Disposition The animal inflicting the bite may be kept 
, for two weeks and if at the end of that time 
Animals ^ has remained well, it was not rabid. If 
symptoms develop the animal should be killed, 
and its head sent to a laboratory for exami¬ 
nation. 


Treatment 
of Persons 
Bitten 


If there is reason to believe that the animal 
was rabid the Pastuer treatment should be 
employed by the person bitten as soon as pos¬ 
sible. 


Prognosis Of persons bitten by rabid animals probably 
less than one-half develop the disease, even 
though not treated- There is less danger if 
bitten through the clothing and the farther 
from the head the less the danger. When 
symptoms develop death is considered in¬ 
evitable, if it is a true case of rabies. 

Hysterical or pseudo-hydrophobia some¬ 
times occures. 

Prophylactic Muzzling and other proper restraint of dogs 
Measures has proven a most efficient prophylactic meas¬ 
ure. 


Within the past few years Anti-Rabic Virus 


83 


Use of Anti> 
Rabic Virus 
Prophylac- 
tically for 
Dogs 


Endorsement 
by California 
State Board 
of Health 


Rabies 

Among 

Wild 

Animals 

Control by 
Cooperation 


has been used prophylactically for the pro¬ 
tection of dogs from rabies: the protection 
is said to last for one year. The California 
State Board of Health, October 7, 1922, ap¬ 
proved this method by incorporating it in 
Rule 7A and recommending its use. They in¬ 
form us through their Bulletin, that control 
of the dog population, preferably by vaccina¬ 
tion against rabies, together with the destruc¬ 
tion of all unvaccinated dogs, will eliminate 
this truly terrible disease. Coyotes and other 
wild animals are subject to this disease and 
may introduce it among domestic animals, 
from time to time. 

Rabies, like other endemic diseases spreads 
through communities in progressive waves, 
With Health or periods of greater or less prevalence and 
Authorities intensity, according to the character of the 
disease. These may be controlled according 
to our knowledge of the causative factors and 
the co-operation of the people with competent 
health authorities. Rabies is one of the dis¬ 
eases which can be almost entirely prevented 
and readily controlled, by measures previously 
discussed. 

As an example of the spread of the disease 
when the health authorities lack proper co¬ 
operation the following summary of statistics 
of the animal and human rabies in California 
during the past three years, compiled from 
the records of the State Board of Health, is 
of interest. Where co-operation has been 
lacking the prevalence of the disease has the 


Example of 
the Spread 
of Rabies 


$4 


Protect 

Against 

Rabies 


more markedly increased. Each case, whether 
animal or human, is also the record of a 
death; recovery after symptoms are manifest 
does not occur; death from rabies is one of 
the most horrible forms of death. 

During the year 1921 cases of rabies were 
reported from twenty counties in California. 
During the years 1922 and 1923 to December 
15th, reports of cases have been received 
from twelve additional counties. 

During the years 1922 and 1923, to Dec¬ 
ember 15th, there have been recorded 695 
persons who have been bitten by rabid ani¬ 
mals and who have received anti-rabic treat¬ 
ment at the public laboratories and Los Ange¬ 
les General Hospital. The number treated 
by private physicians I do not know. 

If you love your dog have it protected. If 
you love your family have your dog protected. 
If you do your best to protect your dog and 
family, you will aid in the protection of the 
community. 

No health department is stronger than the 
expressed sentiment of the community will 
permit it to be. It will be your privilege as 
dentists to do your part toward educating 
those with whom you come in contact, in re¬ 
gard to public health measures, and to sup¬ 
port scientific health legislation and enforce¬ 
ment. 


85 


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86 


Outside of L. A. City 



Scabies 


Impetigo 

Contagiosa 


Ring Worm 


Favus 


Erysipelas 


SOME COMMON DISEASES OF THE 
SKIN 

A contagious disease of the skin caused by 
a small animal parasite which burrows into 
the skin. It is seen between the fingers, on 
the tender surfaces, as the inner side of fore¬ 
arm, and about the genitalia. 

An acute inflammatory contagious disease 
of the skin characterized by superficial vesico- 
pustules. It is seen principally on the scalp, 
face and hands. It is an unknown micro- 
organism. 

(Tinea Trichophytina) is a contagious disease 
of the skin caused by a vegetable parasite. 
It may affect the body, the scalp or the beard. 

A contagious disease of the skin due to a 
vegetable parasite. It is usually seen on the 
scalp and appears as a crust under which is 
pus and scaling skin. 

An acute infectious disease of the skin 
caused by a streptococcus. It appears as 
sharply defined areas of redness. It is very 
dangerous if it comes in contact with open 
wounds. 


87 




CANCER 


* 


r 








































CANCER 

Mortality The death rate from cancer is increasing. 

This disease is now the subject of organized 
study which in the United States has found 
expression in the organization of The Amer¬ 
ican Society for the Control of Cancer. The 
basic principle of this organization for the 
Control of Cancer is, Cancer is a Curable Dis¬ 
ease if Recognized and Treated in the Early 
Stages. 

From their reports the following conclusions 
may be drawn: 

Cancer is one of the most important causes 
of death. It is now the cause of at least 
90,000 deaths annually in the United States. 

The recorded cancer death rate is increasing 
in every country. In the United States it has 
risen from 62.9 per 100,000 of population in 
1900 to 81.6 in 1917. 

A large percentage of these deaths from 
cancer could be prevented if both the public 
and the medical profession were fully edu¬ 
cated in what they each ought to know about 
the disease and if they would seek treatment 
at the first appearance of danger signals. 

Curability Cancer is curable because it is believed not 
to be a “constitutional” or “blood disease,” but 
always at first to be a local disease beginning 
in a single small spot. While it is still con¬ 
fined to the place where it begins it usually 
can be entirely removed from the body by 
competent treatment. 


91 


It has been thought that cancer is due to a 
specific organism. Much work has been done 
to prove this to be true, but up to the present 
time such efforts have failed. What may be 
discovered, I cannot predict. It is incumbent 
that we use the knowledge at hand to the best 
of our ability. 

Pathological Cancer is believed to be a lawless growth 
Development of body cells, which take on an abnormally 
rapid growth, and which destroys life if al¬ 
lowed to run its course. The abnormal growth 
thus started continues until surrounding tis¬ 
sues are invaded. Eventually part of the orig¬ 
inal growth may break off and be carried in 
the blood or lymph vessels to other parts of 
the body, where it starts secondary growths 
that lead to the common but erroneous belief 
that cancer is a constitutional or blood dis¬ 
ease. From this description it is apparent 
that cancer, when it first begins, is a purely 
local growth and therefore removable and cur¬ 
able. There is a danger of spreading by man¬ 
ipulation, rubbing, or the application of ir¬ 
ritants. 

Avoid Cancer arises after long-continued irrita- 

Irritation tion of various kinds and in or about benign 
growth or ulcerations. 

Persistent ulcerations, cracks and sores, 
warts, moles or birthmarks, which change in 
appearance or grow larger, should be removed, 
and tissues subjected to irritation kept under 
intelligent observation. 

After cancer has actually developed, it is in 


92 


Cancer of 
the Lip 


Cancer 
of the 
Tongue 


Heredity 


many cases still curable, but there must be no 
delay. The possibility of curing cancer by 
operation is much greater than most people 
realize. 

Cancer of the lip and mouth may arise from 
pipe smoking, bad teeth, the carrying of pen¬ 
cils, nails, or other irritant substances in the 
mouth. 

Excessive smoking, syphilis, and broken 
teeth are important causative factors. Numer¬ 
ous cases have been traced to badly fitting or 
broken dental plates. Smoking, as a form of 
chemical irritation, produces a chronic inflam¬ 
mation of the tongue and the formation of 
small fissures or ulcers. Any ulceration of 
the tongue that does not quickly respond to 
treatment should be considered malignant until 
it is proved otherwise. Cancer of the tongue 
spreads rapidly and the operation is severe 
and dangerous, and only if the case is seen 
early and promptly treated is there a fair 
chance for a permanent cure. Nitrate of 
silver or other caustics must not be applied to 
irritative ulcers of the tongue. Such treat¬ 
ment in a case of unrecognized cancer will 
stimulate the malignant growth. What has 
been said of the tongue is true of the other 
tissues of the mouth. 

The existence of cancer families, an argu¬ 
ment sometimes brought forward as evidence 
of hereditary influences, does not afford def¬ 
inite proof of the general inheritability of 
this disease, for such families are not very 


93 


Summary 

and 

Conclusion 


frequent and the occurrence of a considerable 
number of cases in a given family can be ex¬ 
plained as a purely accidental occurrence. At 
the present time the only verdict that can be 
furnished it “not proven.” The thought of 
heredity should not lead to worry, for cancer 
to a certain extent goes hand in hand with 
longevity. 

(a) The ravages of this disease can be 
diminished by the dissemination of knowledge 
leading to its early recognition by the patient 
and physician. The American Society for the 
Control of Cancer, the various medical soci¬ 
eties, boards of health, insurance companies, 
women’s clubs and other agencies are endeav¬ 
oring to bring to the people the message of 
hope that cancer is curable in the majority of 
cases if treated early. These facts are being 
established by the work of research labora¬ 
tories and hospitals and the improving of sta¬ 
tistics of clinics, insurance companies and 
public authorities. 

(b) The following points should be espec¬ 
ially remembered: 

(1) Cancer is not a “blood disease” but 
always starts as a local affair. Hence 
it can always be cured by removal if 
discovered and treated early enough. 

(2) Cancer in the beginning may cause no 
pain or other symptoms of ill health. 

(3) Cancer is probably not hereditary. 

(4) Contagiousness of cancer has not been 
demonstrated. 


94 


(5) No treatment should be applied to a 
condition that might develop into a 
cancer without thorough examination. 

(6) The cancer patient must learn to seek 
treatment promptly. 


95 




DISEASES OF 
METABOLISM 


DIABETES MELLITUS 
DIABETES INSIPIDUS 
SCURVY 










Vitamines 


DISEASES OF 
METABOLISM 

Vitamines are substances, other than pro¬ 
tein, carbohydrate and fat, which are found 
in certain plant and animal tissue, and whnch 
are indispensable to the normal life processes. 
They have never been isolated. The field is 
almost unexplored, but certain it is that they 
are factors, in all diets, that are directly re¬ 
lated to health. We do not know as yet the 
exact nature of an emzyme or a toxin or anti¬ 
toxin. No medical man ever doubts their 
existence, and although we do not know their 
exact nature yet we use them therapeuticly. 
So also with vitamines. We have no exact 
knowledge, but we use what is known while 
untiring investigators continue the search. 

Some forty years ago, beri-beri (a disease 
of the Orient) was found to be associated 
with a faulty diet. The disease was at last 
produced in animals by feeding them on an 
exclusive diet of polished rice. Later the 
substance extracted in polishing the rice was 
given the animal and a cure resulted. In 1911 
it was thought the active principal had been 
isolated and that it was a substance showing 
the characteristics of an amine. Accordingly, 
as it seemed so vital to life, it was called 
vita-amine. Later studies proved the isola¬ 
tion wrong, but the name remained and is 
applied to the new field of study. 


99 


It is known that a substance rich in one 
vitamine does not contain another. Thus cod 
liver oil and butter fat possess the fat soluble 
vitamine while they do not possess the vita- 
mines found in yeast, and neither of them 
possess certain others found in orange juice. 
Again these vitamines may be found in the 
fresh stage and be destroyed by cooking. 

The average family under our normal eco¬ 
nomic conditions is not in danger of beri-beri 
or scurvy. There is, however, a tendency on 
the part of the manufacturer to refine away 
many of the food products to such a degree 
that the vitamines are either partially or total¬ 
ly removed. The public demands what is 
pleasing to the eye and palate, and what can 
be prepared with the least time and money. 
The result is that in a land of plenty there 
is more malnutrition than should be found. 
With the variety of foods available for the 
American table, it is possible to adjust the 
selection so that all vitamines and other nut¬ 
rients are present. 

With the sick who have a poor or perverted 
appetite and abnormal digestive and assimi¬ 
lative powers, a careful study has to be made 
of the food. 

DIABETES M ELL IT US 

Definition A nutritional disorder characterized by an 
excess of sugar in the blood and its persistent 
excretion in the urine, which is much in¬ 
creased. 


100 


Pathology 


Symptoms 


Compli¬ 

cations 


Diagnosis 


Prognosis 


The blood contains an excess of sugar and 
fat globules. 

The invasion is usually gradual. Urine is 
passed frequently, six to forty pints in twenty- 
four hours; is pale, with a specifis gravity of 
1025 to 1045 (sometimes lower with chronic 
nephritis) ; contains 1 to 10 per cent of glu¬ 
cose, often acetone, diacetic acid—also oxy- 
butyric acid during coma. There are abnor¬ 
mal thirst and appetite, often loss of weight 
and strength, sometimes constipation, head¬ 
ache and depression. The mouth is dry, the 
tongue red and glazed and the skin dry. Prog¬ 
ress is more rapid the younger the patient. 
Death usually occurs in diabetic coma; in 
others it results from complications. 

Frequently boils and carbuncles, lobar or 
broncho-pneumonia, pulmonary tuberculosis, 
gangrene or perforating ulcer of the foot, 
and indolent ulcers of the plantar surfaces 
of the toes. 

By persistence of glucose in the urine, 
which is usually of high specific gravity (Feh- 
ling’s and Benedict’s solutions, and Purdy’s 
solution for quantitative test). 

Recovery has been rare until the recent dis¬ 
covery of insulin. In patients under forty 
years the outlook is worse; in those over 
forty the progress is slow and the symptoms 
are milder. Resistance to bacterial infection 
is low; wounds heal poorly and extensive 
ulceration is liable to follow operative pro¬ 
cedure. 


101 


Insulin 


Definition 

Etiology 

Symptoms 


One of the most brilliant advances in thera¬ 
peutics of recent years was announced in 
March, 1922, in the Canadian Medical Jour¬ 
nal by Banting, Best, Collip, Campbell and 
Fletcher in which they reported the success¬ 
ful use of insulin in seven cases of dia¬ 
betes mellitus. Their observations have been 
coroborated since that time by many physi¬ 
cians throughout Canada, the United States 
and Europe. 

Insulin is an extract of the pancreas which 
contains the active principle of the Islands 
of Langerhans. 

If properly administered, it will enable the 
diabetic to continue his ordinary vocation. By 
its use the diabetic may be put into such con¬ 
dition that he will be an average good sur¬ 
gical risk. Diabetics who have reached the 
state of coma may by its use be restored to 
consciousness within a few hours, and later 
to useful life. 

DIABETES INSIPIDUS 

A chronic disease characterized by the per¬ 
sistent passage of large quantities of urine of 
low specific gravity. 

Most often in young males. Probably of 
nervous origin. Syphilis is often present. 

The onset is usually gradual. The urine 
is pale, ten to twenty quarts per day, specific 
gravity 1001 to 1005, total solids often nor¬ 
mal. There is thirst, dryness of the mouth 


102 


Differential 

Diagnosis 


Scurvy 


Etiology 


Pathology 


Symptoms 


Diagnosis 


and skin. Appetite and general condition are 
usually normal, sometimes there is feeble¬ 
ness and emaciation. Death may occur from 
intercurrent disease. 

From diabetes mellitus, which is of great¬ 
est importance, by the low specific gravity 
of the urine and absence of sugar. 

SCURVY 

is a metabolic disorder characterized by weak¬ 
ness, anemia, sponginess of the gums and ten¬ 
dency to hemorrhage. 

Prolonged diet lacking in the vitamines 
that are found in fresh vegetables, fruits and 
certain animal fats. 

The gums are swollen and sometimes ulcer¬ 
ated ; there are small hemorrhages in the skin, 
mucous and serous membranes, muscles, etc., 
and albuminous degeneration in the heart, 
liver and kidneys. 

A gradual onset of weakness and anemia, 
the gums are spongy and bleed easily, the 
teeth loosen, there are hemorrhages in the 
skin, the appetite is poor, the heart action 
weak, there is general depression and head¬ 
ache. 

There is a history of foods deficient in va¬ 
riety, bleeding of the gums is present and 
general debility. 

Such patients are poor operative risks. 


103 



MISCELLANEOUS 


Alcoholism 

Opium 

Cocaine 

Hyperthyroidism 

Thymus Disease—Status Lymphaticus 



Hyper¬ 

thyroidism 


Status 

Lymphaticus 
—Thymus 
Disease 


MISCELLANEOUS 

A disease due to increased activity of the 
thyroid gland. In typical cases there is ap¬ 
preciable enlargement of this gland, accom¬ 
panied by increased metabolism, prominence 
of the eyeballs, rapid pulse, fine muscular 
tremors, with marked irritability. The pat¬ 
ients are frequently under weight. The fine 
muscular tremor is readily observed if the 
eyelids are closed, and also by forcibly ex¬ 
tending the fingers and spreading them wide 
apart. Progressive cardiac weakness may de¬ 
velop and sudden death follow a moderate 
shock. Such cases are unfavorable for op¬ 
erative procedure. 

Hyperthyroidism may result from infection 
of the investing tissues of the teeth. 

(Thymus Hyperplasia). These conditions are 
recognized by some authors as the same con¬ 
dition ; by others as a different disease. Status 
lymphaticus is a diseased condition charac¬ 
terized by coincident hyperplasia of the lymph 
nodes, the tonsils, adenoids, spleen, and at 
times of the heart and arteries, also the thy¬ 
mus gland. There is a great tendency to 
sudden death, more especially during early 
life, although the tendency may continue into 
adult life. It is of especial importance in re¬ 
lation to deaths accompanying minor opera¬ 
tions and anesthesia, the cause of death not 
being definitely known. Dilatation of the left 


107 


ventricle of the heart has been reported in 
some cases. 

Thymus Thymus hyperplasia is considered by some 
Hyperplasia £ 0 occur as a more prominent and indepen¬ 
dent factor than suggested by the above. The 
thymus gland may be enlarged from two to 
four times its normal size, giving an area of 
marked dullness over the manubrium, on per¬ 
cussion ; if the lower border rises with ex¬ 
tension of the head and falls with flexion, 
it is quite suggestive of enlargement of the 
thymus, and this probability is increased if 
dyspnea is induced by throwing the head back, 
thus bringing pressure on the trachea. 

A history of unexplained suffocative dys¬ 
pnea and cyanosis occuring in babies and 
young children should place the physician on 
his guard, and these conditions demand most 
careful observation and radiography. It is 
of great importance in its relationship to sur- 
den deaths in children and young adults not 
only without apparent cause, but in connec¬ 
tion with operative or therapeutic procedures, 
the so-called (< thymic death ” 

Alcoholism (Acute and Chronic). The face in alcoholism 
Chrontc> nd ’ s rec ^ t ^ le ca PiH ar ies are dilated, the eyes 
watery, and the conjunctivae congested. In 
the chronic form there is cirrhosis of the liver, 
tremor of hand or tongue, sometimes neuritis 
or paralysis. Arterio-Sclerosis and cardiac 
dilatation are common. Alcoholics are not 
good operative cases as they do not stand 

108 


Opium 

Habit- 

Morphine, 

Heroin, 


Cocaine 


shock, and are predisposed to post-operative 
pneumonia. 

One of the appalling things before the med¬ 
ical world today is the increase in the number 
of habitues. The habit is acquired by repeat¬ 
ed uses of the drug. More than half of the 
users have been taught to use it by an addict. 

The user after taking the drug has an im¬ 
mediate feeling of well being. This is follow¬ 
ed by weariness and sometimes nausea. These 
symptoms are relieved by repeating the dose. 
Eventually the person becomes thin, sallow 
complexioned with pupils dilated or irregular 
(except after immediate taking of the drug), 
the appetite is poor, there is sometimes itch¬ 
ing of the skin, restlessness, irritability and 
a tendency to moral deterioration, and in par¬ 
ticular to untruthfulness. The withdrawal of 
the drug after the habit has been acquired is 
accompanied by most intense suffering. 

The use of opiates should he avoided ex¬ 
cepting under the most urgent need, during 
an emergency, and should never he given for 
several days consecutively. 

What has been stated regarding the bane¬ 
ful effects of opiates is equally true of the 
use of cocaine. It is a habit-forming drug 
which undermines the physical and mental 
health of the user and should be used only 
when necessary and with the greatest caution. 


109 


INDEX 


ACUTE INFECTIOUS 

DISEASES . 70 

ACUTE POLIOMYEL¬ 
ITIS (Infantile Pa¬ 
ralysis) . 77 

ADENOIDS, POST¬ 
NASAL . 42 

Importance of . 42 

ALCOHOLISM .108 

ANGINA PECTORIS .... 66 
APPEARANCE, GEN¬ 
ERAL . 13 

Anemia . 13 

Color—Drug Poison¬ 
ing .15, 16 

Color—Heart Disease.... 14 

Color, high . 15 

Cyanosis . 14 

Eyelids, baggy . 17 

Eyelids, wrinkled . 17 

Jaundice . 16 

Pallar, nephritis . 17 

ARTERIO-SCLEROSIS.. 23 

Blood Pressure . 29 

Determination—tech¬ 
nique . 29 

High—meaning of .... 29 

Low—meaning of. 31 

CANCER . 91 

Conclusions . 94 

Curability . 91 

Heredity . 93 

Mortality . 91 

Produced by irritation.... 92 

CHICKEN POX . 75 

COCAINE HABIT .„109 

CYANOSIS . 14 


DIABETES MELLITUS 100 

Diagnosis .101 

Insulin .102 

DIABETES INSIPIDIS..102 

DIAGNOSIS . 9 

Physical . 10 

Scope .. 9 

DIPHTHERIA . 45 

Antitoxin . 46 

Complications . 46 

Pathology . 46 

Symptoms . 46 

Toxin—Antitoxin . 47 

DISEASES, Acute, In¬ 
fluence on surgical 

operations . 19 

DISEASES OF META¬ 
BOLISM . 99 

ERYSIPELAS . 87 

FAVUS . 87 

FEVER . 24 

Clinical thermometer .... 24 
Diagnostic importance.... 25 
GERMAN MEASLES 

(Rubella) . 73 

HEART and BLOOD¬ 
VESSELS . 27 

HEART - INFLUENCE 
OF FOCAL IN¬ 
FECTIONS UPON.. 62 

Angina Pectoris . 65 

Drop Heart . 63 

Endocarditis . 62 

Myocardial changes . 64 

HISTORIES .:. 9 

Clinical . 22 

Record Taking . 9 

HOARSENESS . 19 


HYPERTHYROIDISM.. 107 


I 






















































IMMUNITY . 36 

Ehrlichs theory . 39 

Acquired . 36 

Metchnikoff’s theory .... 36 

Natural . 36 

IMMUNIZATION . 40 

Active . 40 

Passive . 40 

IMPETIGO CONTAG¬ 
IOSA . 87 

IMPORTANT INFECT¬ 
IOUS CONDITIONS 69 
Symptoms—definitions 69 

INFECTIONS . 35 

INFECTIOUS DISEAS¬ 
ES OF RESPIRA¬ 
TORY TRACT . 42 

INSPECTION . 13 

Appearance, general . 13 

First Impressions . 13 

INSULIN .102 

LARYNGITIS . 44 

MEASLES . 72 

MUMPS . 77 

NEPHRITIS . 18 

Baggy Eyelids . 17 

Palor . 17 

Uremia . 18 

OPIUM HABIT .109 

PHYSICAL SIGNS . 13 

PLAGUE . 79 

PULSE—ARTERIAL .... 27 

Frequency . 28 

Observation of . 27 

Rabies . 82 

RING WORM . 87 

SCABIES . 87 

SCARLET FEVER . 70 

DIAGNOSIS . 71 

SCURVY .103 


SERUMS . 39 

SKIN, Some of the com¬ 
mon diseases of . 87 

SMALL POX .. 73 

Diagnosis . 75 

Symptoms . 74 

STATUS LYMPHAT- 

ICUS .107 

SYMPTOMS .9, 24 

Fever . 24 

Objective .9, 10 

Pathognomonic . 10 

Subjective . 9 

Sweating. 19 

SYPHILIS . 18 

Temperature .24, 25 

Tuberculosis, incipient . 25 

THERMOMETER, 

CLINICAL . 24 

Precautions for use . 24 

THYMUS DISEASE ....107 
THYMUS HYPER¬ 
PLASIA ..108 

TONSILLITIS 

Acute catarral . 43 

Follicular . 43 

Chronic Follicular . 43 

TUBERCULOSIS . 49 

Decrease in tuberculosis 55 
Development of resist¬ 
ance . 50 

Infection almost uni¬ 
versal . 50 

Infection compatible 

with health . 51 

Influence of focal in¬ 
fections on t)he tur 

berculous . 54 

Limit operative pro¬ 
cedure . 55 

Manner of arrestment.... 51 


II 





























































Operations on the 

tuberculous. 54 

Pathological history .... 53 
Reactivation by ab¬ 
scess . 52 

Sodium succinate . 60 

STRESSES . 52 

Bacterial . 52 

General . 52 

Mechanical . 52 

TUBERCLE, a healed 
tuberculous lesion . 49 


TUBERCULIN, admin¬ 
istration of . 60 

TYPHOID FEVER . 78 

TYPHUS FEVER . 79 

UREMIA ., 18 

VACCINES . 39 

VACCINES, ADMINIS¬ 
TRATION OF . 59 

Sodium succinate . 60 

Tuberculin, dose of . 60 

WHOOPING COUGH .. 76 


♦ 


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